Surgery For Stress Urinary Incontinence Research Articles

STRESS URINARY INCONTINENCE: A TEN YEARS SYSTEMATIC REVIEW

Introduction: Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) affect a substantial percentage of women, significantly impacting their quality of life. This review explores the prevalence, definitions, and pathophysiology of SUI, POP, and associated urinary incontinence, emphasizing the need for medical attention and offering insights into current treatment trends over the past 5 years. Methods: The researchers in this study followed the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to ensure that their work met the required standards. This was done to ensure the precision and reliability of the conclusions derived from the research. Result: Our search produced 21 results. After looking at the titles and summaries, we found 9 papers that fit our criteria. At first, we excluded several articles because they were written in review style. But after reading the full papers carefully, we included five papers in our final analysis. These papers included a retrospective observational study, prospective study, and randomized control trial. Conclusion: In this decade-long systematic review on stress urinary incontinence (SUI), notable findings include a 2.2 prevalence of SUI operations post-hysterectomy, persistent links between vaginal hysterectomy (VH) and SUI operations, and significant associations with preceding pelvic organ prolapse (POP), vaginal deliveries, laparoscopic hysterectomy (LH), and urinary incontinence (UI) visits. Combining pelvic floor muscle (PFM) strengthening with hip synergic muscle exercises improves daily urine loss frequency, while modifiable risk factors such as achieving an ideal body weight and preventing traumatic vaginal delivery are identified for SUI prevention. Cost analysis indicates that savings from avoiding unnecessary surgical treatments through urodynamic investigations (UDIs) in uncomplicated patients cover associated expenses, emphasizing the need to consider potential legal actions in a comprehensive cost assessment of negative externalities

Cosmetic and functional impact of fascia lata harvest for use in surgery for stress urinary incontinence.

There has been increased interest in using autologous tissues since the Food and Drug Administration banned transvaginal mesh for pelvic organ prolapse in 2019. Our study aims to assess patients' perspective of functional and cosmetic impact on the fascia lata harvest site in patients undergoing fascia lata harvest for the treatment of stress urinary incontinence (SUI). This is a prospective survey study of a retrospective cohort of patients who underwent a fascia lata pubovaginal sling between 2017 and 2022. Participants completed a survey regarding the functional and cosmetic outcomes of the harvest site. Seventy-two patients met the inclusion criteria. Twenty-nine patients completed the survey for a completion rate of 40.3%. For functional symptoms, 24.1% (7/29) of patients reported leg discomfort, 10.3% (3/29) reported leg weakness, 10.3% (3/29) reported a bulge, 17.2% (5/29) reported scar pain, 14.8% (4/27) reported scar numbness, and 17.2% (5/29) reported paresthesia at the scar. For cosmetic outcomes, 72.4% (21/29) reported an excellent or good scar appearance. On the PGI-I, 75.9% (22/29) reported their condition as very much better (48.3%, 14/29) or much better (27.6%, 8/29). The majority of patients reported being satisfied with the functional and cosmetic outcomes of their harvest site as well as satisfied with the improvement in their SUI. Less than 25% of patients report harvest site symptoms, including leg weakness, scar bulging, scar pain, scar numbness, or paresthesia in the scar. This is important in the context of appropriate preoperative discussion and counseling regarding fascia lata harvest.

Changes in Stress Urinary Incontinence Symptoms after Pelvic Organ Prolapse Surgery: a Nationwide Cohort Study (FINPOP).

Various strategies are employed to manage stress urinary incontinence (SUI) during pelvic organ prolapse (POP) surgery. This study was aimed at facilitating shared decision-making by evaluating SUI symptom changes, staged SUI procedures, and their prognostic factors following POP surgery without concomitant SUI intervention. We analyzed 2,677 POP surgeries from a population-based observational cohort, excluding patients with prior SUI surgery. The outcome measures were subjective SUI utilizing the Pelvic Floor Distress Inventory-20 questionnaire and number of subsequent SUI procedures. Multivariable linear models were applied to identify predictors of persistent SUI, procedures for persistent SUI, and de novo SUI. The primary assessment occurred at the 2-year follow-up. At baseline, 50% (1,329 out of 2,677) experienced SUI; 35% (354 out of 1,005) resolved, an additional 14% (140 out 1,005) improved, and 5.1% (67 out of 1,308) underwent a procedure for persistent SUI. De novo SUI symptoms developed in 20% (218 out of 1,087), with 3.2% (35 out of 1,087) reporting bothersome symptoms; 0.8% (11 out of 1,347) underwent a procedure for de novo SUI. High baseline symptom severity increased the risk of persistent SUI (adjusted odds ratio [aOR] 2.04, 95% confidence interval [CI] 1.65-2.53), whereas advanced preoperative apical prolapse decreased the risk (aOR 0.89, 95% CI 0.85-0.93). De novo SUI was more common with advancing age (aOR 1.03, 95% CI 1.01-1.05), baseline urgency urinary incontinence (aOR 1.21, 95% CI 1.06-1.38), and after transvaginal mesh surgery (aOR 1.93, 95% CI 1.24-3.00). It was not dependent on the compartment or preoperative degree of prolapse. In a pragmatic setting, POP surgery results in a low rate of subsequent SUI procedures.

Pain Catastrophizing and Impact on Pelvic Floor Surgery Experience

ABSTRACT Duration, intensity, and management of pain and discomfort may all be affected by experience, personality, and medical and psychosocial comorbidities. A negative cognitive-affective response to actual or anticipated pain, which impacts the pain experience, is called pain catastrophizing. The scale utilized for identifying individuals who magnify, feel helpless to manage, anticipate, or ruminate on pain is known as the Pain Catastrophizing Scale (PCS) and is composed of a 13-question validated measure and 3 subscales. The scale's score ranges from 0 to 52, where scores of 30 and greater indicate pain catastrophizing (30 points is the 75th percentile for PCS score distribution in patients with chronic pain). Pain catastrophizing is associated with increased pain severity, pain persistence, and opioid consumption following surgery, as well as poorer response to endometriosis treatments. Approximately 300,000 prolapse surgical procedures are performed in the United States annually, and because little is known about pain catastrophizing on perioperative pain, pelvic floor symptom distress/impact, and voiding trial (VT) performance following urogynecologic surgery, the authors' primary aim was to assess baseline pain catastrophizing on preoperative pelvic floor symptom impact and distress. The secondary aims included assessing the impact of pain catastrophizing on voiding function and postoperative pain following pelvic floor surgery. The patients for this prospective cohort study included self-identifying female patients undergoing surgery for stress urinary incontinence (SUI) and/or pelvic organ prolapse from March 2020 to December 2021. Inclusion came following completion of appropriate surveys and subsequent surgery. Exclusion was merited through surgery for reasons besides SUI or prolapse. At the baseline patient visit, a PCS score of 30 or greater was defined as pain catastrophizing. The initial visit also included recording data such as body mass index, age, benzodiazepine use, chronic opioid use, anxiety and depression diagnoses, postoperative prolapse stage, bothersome urgency urinary incontinence, and preoperative postvoid residual volume. Charts were used for abstracting surgical data, such as operative time, estimated blood loss, type of pelvic reconstructive surgery performed, and midurethral sling placement. Surgeries were all performed by fellowship-trained reconstructive pelvic surgery providers. Postanesthesia care unit (PACU) nurses and clinic staff were masked to preoperative PCS scores obtained in the PACU and postoperative clinic visits. A standardized void trial was performed. Of 320 participants in this cohort, 46 had a pain catastrophizing score of ≥30. Mean age was 60.0 ± 12.8 years. Bivariate analysis indicated that the pain catastrophizing group had higher average body mass index and greater preoperative use of benzodiazepines. Variants such as SUI rates, urgency urinary incontinence, or prolapse stage had no significant differences between groups, yet preoperative pelvic floor symptom distress and impact scores were clinically and statistically significantly higher in the catastrophizing group. Higher PACU pain scores were associated with pain catastrophizing, but not first postoperative VT failure. A significant association between pain catastrophizing and symptom distress remained following multivariable analysis, as well as a relationship between high PCS scores and symptom impact. All quality-of-life subscales maintained the significant associations. This study, although unique in describing pain catastrophizing in this setting, includes various limitations such as its single-institutional nature, which may limit external generalizability. Furthermore, generalizability may also be limited for those electing nonsurgical management, as the study selected for women choosing surgery. Study strengths include its large number of patients cared for by fellowship-trained providers in a similar manner with uniform surgical practice and timing of measures for assessing pelvic pain and pelvic floor symptoms. Also, a relatively standard VT method was utilized. Although further investigation is warranted for describing pain catastrophizing and its role with pelvic floor symptoms and pain postoperatively, the results of this study support other investigative findings, which indicate the importance of understanding pain catastrophizing and its potential effect on patients undergoing pelvic floor surgery. Future studies around this relationship can potentially enable health care providers to tailor perioperative care for individuals with pain catastrophizing.

The Impact of Preoperative Pain on Outcomes After Vaginal Reconstructive Surgery and Perioperative Pelvic Floor Muscle Training

ABSTRACT In the United States, around 9 million women are affected by pelvic pain due to conditions such as interstitial cystitis/bladder syndrome, fibromyalgia, pelvic floor myalgias, chronic opioid use, or irritable bowel syndrome. Treatment options for concurrent pelvic floor disorders and pelvic pain can prove challenging due to the overall desire to avoid exacerbating overall pain while optimizing pelvic floor symptoms. The primary aim of this study was to compare both perioperative pelvic muscle training and vaginal reconstructive surgery among women who experienced or lacked preoperative pain and to inform better approaches to management of women with preoperative pain. The study was a secondary analysis of the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) randomized clinical trial, as performed via the Pelvic Floor Disorders network. The main study's design was a 2 × 2 randomized factorial design with a surgical intervention and a perioperative behavioral intervention. The Eunice Kennedy Shriver National Institute of Child Health and Development data and specimen hub provided the data for this study. Included were 374 women undergoing surgery for both stress urinary incontinence and stage 2–4 pelvic organ prolapse from 2008 to 2013. All participants underwent vaginal prolapse repair and midurethral sling, and were randomized to either perioperative pelvic muscle therapy or usual care. The Pain scale, the Pelvic Floor Impact Questionnaire, the Pelvic Floor Distress Inventory, and the Patient Global Impression of Improvement were all completed by patients at baseline and repeated through month 24. The OPTIMAL trial had a primary outcome of surgical success as defined by anatomical success, but the primary outcome of this secondary analysis was a change in pain scale scores over 24 months after surgery. Three hundred seventy-four women participated in the original trial, with 368 in this secondary analysis. One hundred nine of the 368 women reported preoperative pain. Women with pelvic pain were more likely to be Hispanic, but there were no differences in surgical procedures performed, hospital stay, complications (ie, bladder injury, suture exposure, etc), or estimated blood loss in women with and without pelvic pain. Women with preoperative pain experienced greater pain at all time points, but also exhibited greater pain improvement at 24 months after surgery. Women with preoperative pain had worse baseline pelvic floor symptoms than those without pain. Although women with pain and women without pain had improvements in distress symptoms measured with the Pelvic Floor Distress Inventory, women with pain saw a greater improvement after surgery. All distress subscales improved significantly more in women with pain than women without pain. One additional interesting finding was that women randomized to sacrospinous suspension and pelvic muscle therapy had greater improvements in postoperative pain than those randomized to usual care. Notably, rates of surgical anatomic success and extent of Patient Global Impression of Improvement were not different between women with and without pain. Strengths of the study include its design as a secondary analysis of a large prospective multicenter randomized controlled trial. A substantial proportion of participants reported at least moderate pain at baseline but were not selected based on preoperative pain. Women in the trial were randomized to types of vaginal reconstructive surgery and pelvic muscle training, which allowed the authors to draw conclusions in categories of physical therapy treatments and surgeries for women with and without preoperative pain. Limitations of the study include a lack of preoperative pain data, pain diagnoses, and participant medications in the OPTIMAL trial. Furthermore, the study used no validated pain scale and was limited by OPTIMAL trial data collection intervals. Thankfully, data collected at numerous points over 24 months in some regard accounted for pain symptoms over time. The study found that, for patients with preoperative pain, significant improvement in pelvic floor symptoms and pain takes place after vaginal reconstructive surgery. Similar postoperative improvement rates were found. In addition, perioperative pelvic floor muscle training may be beneficial for patients with planned sacrospinous ligament fixation.

Reconstruction of Urethral Sphincter With Polyacrylamide Hydrogel.

Urethral bulking is an alternative to synthetic midurethral sling for the treatment of stress urinary incontinence (SUI) in women. Urethral bulking agents, which are injected in the submucosal tissues of the proximal urethra/bladder neck, have demonstrated less adverse effects with similar satisfaction rates but lower subjective and objective cure rates when compared with midurethral sling. Cystoscopic Reconstruction of External Sphincter Technique (CREST) is a novel technique, which reinforces the natural closure mechanism of the external urinary sphincter (EUS). The aim of the study was to provide safety and efficacy data for injecting polyacrylamide hydrogel (PAHG) in the components of the female EUS. This was a retrospective chart review of patients using CREST with PAHG as initial treatment for SUI by a single surgeon from January 2022 to October 2022. Exclusion criteria are as follows: younger than 18 years, prior SUI surgery, concomitant pelvic organ prolapse or reconstructive procedure, neurological conditions, or history of radiation. Subjective and objective cure rates were measured by patient-reported symptoms and cough stress test. Urinary retention, postoperative urinary infection, and de novo urinary urgency were assessed. One hundred and thirteen consecutive patients met inclusion criteria with median follow-up of 3 months. Eighty-five percent of participants reported subjective improvement, 69% reported subjective cure, and 69% demonstrated objective cure. Nine patients reported transient postoperative retention, 8 reported postoperative urinary tract infections, and 5 reported de novo urgency. There were no serious adverse events. CREST is a novel technique for injection of PAHG, into the EUS to treat SUI. Our data suggest that this technique could improve urethral injection outcomes with minimal complications.

Унилатеральная гибридная хирургическая реконструкция тазового дна. Модифицированная лоскутная методика

Sacrospinous fixation is one of the most studied treatments for pelvic organ prolapse (POP), but the prevention of implantrelated complications remains unresolved. To isolate the mesh materials from the incision line and to prevent the development of chronic pelvic pain syndrome due to rigid fixation, a modification of hybrid pelvic floor reconstruction was performed, where a U-shaped vascularized vaginal flap acts as the main fixation point of the mesh implant. Objective. To study the efficacy and safety of a modified flap technique for unilateral hybrid pelvic floor surgical reconstruction. Patients and methods. A database of 128 case histories was generated. Inclusion criteria: apical anterior prolapse (POP-Q: Ba, C ≥ 0), hybrid pelvic floor surgical reconstruction using mesh endoprosthesis and vascularized vaginal flap performed between May 2020 and September 2022. The variables under study included POP stage, results of the PFDI-20, PISQ-12, and ICIQ-SF questionnaires, intraoperative complications. Patients who underwent surgery were invited for consultation. The following parameters were evaluated: POP stage, presence of mesh erosion, de novo dyspareunia, de novo chronic pelvic pain, de novo functional disorders (an overactive or atonic bladder, stress urinary incontinence (SUI), defecation disorders), repeat surgeries for POP and SUI. The PFDI-20, PISQ-12, and ICIQ-SF questionnaires were filled in. Satisfaction with treatment was assessed using the PGI-I scale. Four patients underwent contrast-enhanced magnetic resonance imaging of the pelvic organs. Results. The results showed a significant improvement in the quality of life after surgery in 113 (96.6%) cases. Only 3 (2.6%) patients had persistent POP symptoms. Of the 117 patients with baseline moderate or severe urinary incontinence, 45 (38.5%) showed improvement in 41 (91.1%) cases. Assessment of the quality of sexual life showed improvement in 27 (77.1%) of 35 patients, and 4 patients returned to sexual activity after surgery. Satisfaction with the results of treatment was noted in 109 (93.2%) patients. Conclusion. Flap modification for unilateral hybrid pelvic floor surgical reconstruction is an effective and safe method of preventing the development of implant-related complications in the correction of POP. Key words: pelvic organ prolapse, mesh implant, vaginal flap

Evaluating Patient Preferences and Clinical Outcomes in Stress Urinary Incontinence Treatment: A Short-Term Follow-Up Study of the Transobturator Tape Procedure and Pubourethral Ligament Plication (a Minimally Invasive Technique).

This study aims to provide an in-depth analysis of patient preferences and clinical outcomes associated with two surgical techniques for treating stress urinary incontinence (SUI): the transobturator suburethral sling (TOT) procedure and the pubourethral ligament plication (PUL) procedure. We evaluated the rates of postoperative complications, the duration of each procedure, hemoglobin loss, and days of hospitalization. This prospective study included 80 patients who underwent surgery for SUI: 40 patients for the TOT procedure and 40 patients for the PUL procedure. Clinical data on patient characteristics, treatment efficacy, and post-surgical outcomes were analyzed to assess patient preferences and real-world clinical effectiveness. Regarding patient preferences, those who underwent TOT surgery were more likely to be older, had a higher average number of pregnancies, and were more often postmenopausal, in contrast to those who underwent PUL surgery (p < 0.001 for each comparison). TOT patients had a hospital stay on average of 1.02 days, while PUL patients benefited from ambulatory stays only. In addition, the TOT group had a significantly longer average operating time (16.80 min) compared to the PUL group (9.90 min, p < 0.001). The study revealed notable outcomes in both groups, with high cure rates for both TOT (N1 = 33, 82.5%) and PUL (N2 = 28, 70%) procedures. Specifically, 76.25% of the patients (61 out of 80) were cured after the procedures. Chronic pelvic pain was present in 3.75% of all patients and was notably only observed in the TOT group, with 3 (7.5%) cases being noted. Similarly, vaginal erosion was experienced by 5% of all patients, with 10% of patients in the TOT group and none in the PUL group being affected. Dyspareunia occurred in 2.5% of all patients, with there being two (5%) cases in the TOT group and none in the PUL group. This study highlights that while the PUL procedure achieves cure rates comparable to TOT, it offers a less invasive option with shorter operating times and no hospitalization required. These findings suggest that PUL could be a viable alternative for stress urinary incontinence (SUI) treatment, especially in contexts where avoiding mesh use is preferred. This adds significant value to patient-centered care in SUI management, offering tailored treatment options based on patient characteristics, preferences, and risk profiles.

Rates of subjective and objective cure, satisfaction, and pain 10-20 years after tension-free vaginal tape (TVT) surgery: A retrospective cohort study.

To evaluate rates of subjective and objective cure, treatment satisfaction, pain, and the correlation between cure and body mass index (BMI), at 10 and 20 years after tension-free vaginal tape (TVT) surgery. Retrospective cohort study. Multicentre study including 19 units in Norway. Women undergoing TVT surgery for stress urinary incontinence (SUI) during 2001-2006 (20-year cohort) and 2011-2012 (10-year cohort). The Norwegian Female Incontinence Registry was used to identify women eligible for the study, who answered validated questionnaires about urinary incontinence, pain and satisfaction. Subjective cure of SUI (with stress index of <3, range 0-12), objective cure (<3 g on stress test) and persisting pain and satisfaction after TVT (scored on a five-point Likert scale). In total, 1210 of 1903 (64%) patients responded. The subjective cure rate was 68% after 10 years, versus 59% after 20 years, and did not significantly differ after adjusting for age, BMI, parity and preoperative stress index (adjusted OR 1.27, 95% CI 0.82-1.94). The objective cure rate was 100% versus 93% (P < 0.001), with 89% versus 76% reporting subjective satisfaction (P < 0.001), and with 4.7% versus 2.7% reporting persisting pain (P < 0.001), after 10 versus 20 years, respectively. Women in obesity classes I and II, compared with women of normal weight, had an increased risk of not being subjectively cured (crude OR 2.02, 95% CI 1.42-2.90; OR 2.95, 95% CI 1.60-5.46, respectively). Tension-free vaginal tape (TVT) provided high rates of subjective and objective cure at 10 and 20 years after surgery, with no significant difference between the two cohorts. Although 3%-5% of women experienced persisting pain, most women were satisfied with TVT surgery. Obesity was associated with a lower cure rate.

External validation of the de novo stress urinary incontinence prediction model after pelvic organ prolapse surgery in Korean women: a retrospective cohort study

BackgroundDe novo stress urinary incontinence (SUI) may develop following pelvic organ prolapse surgery. Performing prophylactic continence surgery may reduce the risk of de novo SUI and subsequent continence surgery; however, it may increase the risk of complications. Therefore, many surgeons try to identify women at high risk for de novo SUI and perform continence surgery selectively. Recently, a model for predicting the risk of de novo SUI after prolapse surgery was developed using data from the Outcomes following vaginal Prolapse repair and midUrethral Sling (OPUS) trial; its prediction accuracy was significantly better than that of the stress test alone. However, few studies have verified its prediction accuracy in discrete populations. The aim of this study was to externally validate the prediction model for de novo SUI after prolapse surgery in Korean women.MethodsThis retrospective cohort study included 320 stress-continent women who underwent prolapse surgery for pelvic organ prolapse quantification stage 2–4 anterior or apical prolapse and who completed a 1-year follow-up. Predicted probabilities by the de novo SUI online risk calculator were compared with observed outcomes and quantitated using the model’s area under the curve and calibration plot. Subgroup analyses were also performed by the type of prolapse surgery.ResultsThe de novo SUI prediction model showed moderate discrimination in our study cohort; area under the curve (95% confidence interval) = 0.73 (0.67–0.78) in the whole cohort, 0.69 (0.61–0.78) in women who underwent native tissue repair or colpocleisis, and 0.74 (0.65–0.82) in those who underwent sacrocolpopexy. Calibration curves demonstrated that the model accurately predicted the observed outcomes of de novo SUI in women who underwent native tissue repair or colpocleisis but underestimated outcomes in those who underwent sacrocolpopexy. The predicted probability cutoff points corresponding to an actual risk of 50% were 40% in women who underwent native tissue repair or colpocleisis and 30% in those who underwent sacrocolpopexy.ConclusionsThe de novo SUI prediction model is acceptable for use in Korean women and may aid in shared decision-making regarding prophylactic continence procedure at the time of prolapse surgery.

Risk factors for 5-year complications after midurethral sling surgery for stress urinary incontinence: a retrospective cohort study from Taiwan

Midurethral sling surgery is the current gold standard worldwide for stress urinary incontinence (SUI) surgery, with over 90% of surgeons worldwide using the midurethral sling for SUI between 2008 and 2018. However, concerns surround mesh-related adverse events associated with the midurethral sling. The decision to use the midurethral sling for surgical treatment has become a challenging one for clinicians, surgeons and patients. We sought to determine the factors for 5-year complications after midurethral sling surgery, to improve the clinical decision-making process. Records were reviewed from a total of 1961 female patients who underwent their first midurethral sling surgery for SUI between 2003 and 2018 at a single teaching hospital in Taiwan. A multivariable Cox proportional hazard model calculated the hazard ratios of risk factors for surgical complications, after adjusting for confounders. Surgical complications (i.e., secondary surgery and urinary retention) occurred in 93 (4.7%) patients within 5 years following the index operations. These patients were more likely to be older, to have a history of menopausal syndrome within 1 year prior to the index operation, a medication history of oral antidiabetic drug use, hormone replacement therapy (HRT), slower average flow rate, and longer voiding time compared with patients without surgical complications. In the multivariate analysis, HRT (adjusted hazard ratio, 1.787; 95% confidence interval, 1.011–3.158, p = 0.04) was significantly associated with surgical complications at 5 years, after adjusting for age, gender, diabetes, menopause syndrome, average flow rate, and sling type. Our findings suggest that a medication history of HRT may be a risk factor associated with surgical complications, especially urinary retention, at 5 years in women undergoing midurethral sling surgery for SUI.

The use of midurethral sling in the correction of low-stage cystoceles: a prospective randomized trial

Introduction and hypothesisThe objective was to assess whether midurethral slings (MUS) can improve both stress urinary incontinence (SUI) and cystoceles. MUS with anterior colporrhaphy (AC) as a treatment for SUI with cystocele is more invasive and carries greater risk than MUS alone.MethodsThis is a prospective randomized study involving women with stage 1 or 2 cystocele and SUI, who were > 21 years of age, who had had no previous surgery for SUI. Predominant SUI, symptomatic anterior pelvic organ prolapse, and informed consent were mandatory. Patients were randomized as to whether AC had been performed. The sling procedure was left to the surgeon’s discretion: pubovaginal sling, tension-free vaginal tape, or trans-obturator tape. Success was defined as a negative stress test and no evidence of cystocele upon local examination.ResultsNinety-eight patients were enrolled, 48 underwent MUS, and 50 underwent MUS and AC. Mean age ± SD was 44.96 ± 8.13 years. Baseline characteristics were similar. Operative time and blood loss were significantly higher in the MUS/AC group (p = 0.01 and 0.02 respectively). At 3 months, success was 79.1% and 77.8% in the MUS and MUS/AC groups respectively. This was maintained until 6 months (79.1% and 77.8% respectively). At 1 year, the results were comparable with success rates of 96.2% and 87.0% in the MUS and MUS and AC groups respectively. Symptom scores were comparable at 6- and 12-month evaluations.ConclusionMidurethral slings correct symptomatic stage 1 or 2 cystoceles without the need for AC, which carries the risk of a significantly longer procedure and more significant blood loss.

Hemoglobin A1c and Reoperation After Surgery for Stress Incontinence or Prolapse.

Few studies compare the link between hemogobin A1c (HbA1c) and urogynecologic surgical complications. The objective of this study was to determine the association between HbA1c and reoperation in women undergoing surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP). We performed 2 separate retrospective cohort analyses using Cerner's HealthFacts Database (750 hospitals; 519,000,000 patient encounters from January 1, 2010, to November 30, 2018). We included women undergoing surgery for (1) SUI or (2) apical POP by International Classification of Diseases coding who had HbA1c at the initial procedure. Each analysis compared those undergoing reoperation for complications or recurrence and those who did not. Multivariable logistic regression assessed the association between reoperation and HbA1c both as a continuous variable and comparing the commonly accepted cutoff ≥8. Of 30,180 SUI surgical procedures and 26,389 POP surgical procedures, 1,625 (5.4%) and 805 (3.1%) had HbA1c. Median (interquartile range) HbA1c in grams per deciliter was similar by reoperation status (SUI: 6.0 [5.6-6.8] vs 6.1 [5.6-6.9], P = 0.35; POP: 6.2 [5.6-6.6] vs 6.1 [5.7-6.8], P = 0.60). Reoperation was also similar using the HbA1c ≥8% cutoff (SUI: 6.9% vs 7.4%, P = 0.79; POP: 6.3% vs 5.4%, P = 0.77). On multivariate analysis, HbA1c value was not a significant predictor of reoperation either as a continuous (SUI: odds ratio [OR] = 0.966, 95% CI = 0.833-1.119; POP: OR = 1.040, 95% CI = 0.801-1.350) or dichotomous variable ≥8 (SUI: OR = 0.767, 95% CI = 0.407-1.446; POP: OR = 0.988, 95% CI = 0.331-2.951). Mean follow-up was 4.28-5.13 years. Although other studies have shown a link between diabetes and complications, we were unable to show an association between HbA1c values and rates of reoperation.

The impact of vaginal surgical mesh devices on consultation rates by type and health care provider in UK primary care: A cohort study in the Clinical Practice Research Datalink.

To examine consultation rates by type of consultation and health care provider in women with stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP), with and without surgical mesh implants. Longitudinal open cohort study from April 2006 to November 2018 in the Clinical Practice Research Datalink (CPRD). Rates of consultations with general practitioners (GPs), nurses, other clinicians and administrators by consultation type (face-to-face, telephone or administrative), and types of administrative consultations, estimated using negative binomial regression. Of 220,544 women eligible for inclusion, 74% (n=162,687) had SUI, 37% (n=82,123) had POP, and 11% (n=24,266) had both. Face-to-face consultation rates were stable over time, at about 9 per year. Administrative consultations with GPs and administrators increased between 2006 and 2018, but averaged 31 per year. After adjustment, for both SUI and POP mesh surgery, there were lower rates of face-to-face consultations with GPs, higher rates of face-to-face consultations with other clinicians, higher rates of telephone consultations with GPs and other clinicians, and higher rates of administrative consultations with GPs, nurses and administrators. The higher rate of consultations with GPs coded as administrative consisted of results recording and administrative codes, and the higher rates of consultations with administrators were coded as repeat issue, other, administration and third-party consultations. Caring for women with mesh places a higher administrative burden on GPs and administrators. There may be potential to reduce this workload through a more streamlined care pathway.

Serious complications and recurrences after retropubic vs transobturator midurethral sling procedures for 2682 patients in the VIGI-MESH register

BackgroundMidurethral slings are the gold standard for treating stress urinary incontinence, but their complications may raise concerns. Complications may differ by the approach used to place them. Objective(s)To compare serious complications and reoperations for recurrence after midurethral sling procedures by the retropubic and transobturator routes for female stress urinary incontinence. Study DesignThis analysis covers patients included in the French multicenter VIGI-MESH register since February 2017 who received a midurethral sling for female stress urinary incontinence by the retropubic or transobturator route, excluding single-incision slings. Follow-up continued to October 2021. Serious complications (Clavien-Dindo classification ≥ Grade III) imputable to the midurethral sling and reoperations for recurrence were compared by Cox proportional hazard models including any associated surgery (hysterectomy or prolapse) and a frailty term to consider the center effect. Baseline differences were balanced by propensity score weighting. Analyses using the propensity score and Cox models were adjusted for baseline differences, center effect, and associated surgery. Results1830 participants received a retropubic sling and 852 a transobturator sling in 27 French centers, placed by 167 surgeons. The cumulative two-year estimate of serious complications was 5.8% (95% CI 4.8%-7.0%)) in the retropubic group and 2.9% (95% CI, 1.9%–4.3%) in the transobturator group, that is, after adjustment, half that of the retropubic group (adjusted HR 0.41; 95% CI 0.3-0.6). The cumulative two-year estimate of reoperation for recurrence of stress urinary incontinence was 2.7% (95% CI 2.0-3.6) in the retropubic group and 2.8% (95% CI 1.7-4.2) in the transobturator group, with risk of revision for recurrence higher in the transobturator group after adjustment (adjusted HR 1.9; 95% CI 1.2-2.9); this surplus risk disappeared after exclusion of the patients with a previous surgery for stress urinary incontinence. ConclusionsThe transobturator route for midurethral slings is associated with a lower risk of serious complications but a higher risk of surgical reoperation for recurrence than the retropubic route. Despite the large number of surgeons involved, these risks were low. The data are therefore reassuring.

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

AbstractIntroductionThe 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.MethodsA 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.ResultsPossible 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.ConclusionsIdentifying 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 midurethral tape with autologous rectus fascial sling surgery for stress urinary incontinence: A systematic review and meta-analysis

Abstract Objectives To compare the success rates of autologous fascial mesh (sling and transobturator tape [TOT]) with midurethral synthetic meshes (tension-free vaginal tape sling [TVT] and TOT) for stress urinary incontinence. Materials and methods A literature search for studies published in English was conducted from May 10, 2022, to June 1, 2022. The search included MEDLINE/PubMed, Cochrane Library, Scopus, Web of Science, Google Scholar, and ProQuest, using the terms{“Autologous fascial slings”}OR {“AFS”} AND{“TOT”} OR {“Transobturator tape”} OR{“TVT”} OR{“Transvaginal tape”}. A total of 20 studies, including 10 randomized controlled trials, were selected for the review. RevMan software (version 5.3) was used to calculate the pooled effect estimates for operative and postoperative variables. Results In the systemic review, 20 studies, including 10 randomized controlled trials, were assessed. In the TVT versus autologous pubovaginal sling (A-PVS) groups, the effect estimates for the surgical duration, catheter duration, success, and complication rates were more advantageous for TVT. However, in comparison to autologous transobturator tape groups, TOT provided better operative time and a shorter hospital stay. Moreover, in comparison to the A-PVS group, the TOT group was superior in terms of operating time, urethral catheterization, hospital stay, amount of residual urine, and wound complications. The A-PVS group had significantly more groin and thigh pain. Conclusions During medium- and long-term follow-ups, the use of autologous rectus fascia grafts using a A-PVS or TOT provided similar complication rates and urinary continence results as using midurethral synthetic meshes (TVT and TOT).

Cost-Utility Analysis of Midurethral Sling Timing Among Women Undergoing Prolapse Surgery

(Abstracted from Urogynecology 2023; doi: 10.1097/SPV.0000000000001384) Approximately 25% of women in the United States are affected by pelvic floor disorders, with estimates pointing to a 50% increase in urinary incontinence prevalence and pelvic organ prolapse (POP) by 2050. Surgery for stress urinary incontinence (SUI) is also often required, which adds to economic burdens of pelvic floor disorders. Determining the POP patients who would benefit most from concomitant midurethral slings (MUSs) remains a clinical challenge.

Bibliometric analysis of studies on stress urinary incontinence surgery

BackgroundStress urinary incontinence (SUI) is characterized by the involuntary leakage of urine during activities that increase abdominal pressure. In recent years, a considerable number of studies on SUI surgery have been published. However, there has been a lack of systematic quantification and comprehensive summarization of these studies. Bibliometrics is a discipline that utilizes measurement methods to quantify scientific literature. Thus, this study utilized publications from the Web of Science (WOS) as a data source and conducted a comprehensive analysis and visualization of studies related to SUI surgery in recent years using bibliometric techniques. MethodsWe conducted a search and retrieved information on 988 studies related to SUI surgery in the WOS Core Collection. The data covered ten years from September 7, 2013, to September 7, 2023. We employed VOSviewer software, CiteSpace software, and Bibliometrix for analysis and visualization. ResultsOver the ten years, the number of publications exhibited a fluctuating trend, initially decreasing and then increasing. The United States emerged as the leading contributor in terms of both publication volume and quality. The University of Alabama Birmingham ranked as the institution with the highest number of publications, while the International Urogynecology Journal featured the most publications among journals. ConclusionsThis paper presents a bibliometric analysis of publications related to SUI surgery from 2013 to 2023. The aim is to offer researchers a concise overview of the field and inspire future research directions.

Urinary Tract Infections After Urogynecologic Surgery: Risk Factors, Timeline, and Uropathogens

ABSTRACT Postoperative urinary tract infection (PO-UTI) is seen in 6.4%–32% of stress urinary incontinence (SUI) and/or pelvic organ prolapse (POP) surgeries despite perioperative antibiotic prophylaxis. Postoperative complications associated with PO-UTI include increased mortality and longer hospitalization. Increasing prevalence of resistance to antibiotics and antibiotic stewardship principles necessitate both the improvement of infection prevention strategies and judicious antibiotic prescriptions. Four factors are known to increase PO-UTI risk: (1) recurrent UTI (RUTI) history, (2) preoperative UTI, (3) day-of-surgery UTI, and (4) prolonged postoperative catheterization. This study intended to determine (1) risk factors of PO-UTI and PO-RUTI, (2) preoperative and postoperative UTI temporal distribution, and (3) detected uropathogens in a large database. The study used medical record data of all SUI/POP surgical procedures performed in the Kaiser Southern California Hospital system from January 1, 2008 to December 31, 2016 for women 18 years of age or older. Procedures used Current Procedural Terminology codes for identifying and subcategorizing surgical procedures and their route (SUI or POP; abdominal or vaginal, respectively). The study-wide definition of UTI was as follows: (1) positive standard urine culture of greater than 105 CFU/mL of ≤2 uropathogens, or (2) prescription of urinary antibiotics prescribed for the indication of UTI symptoms. The analysis consisted of 21,063 urogynecologic surgical procedures performed on 20,051 women (33,626 POP and/or SUI procedures), with 22,641 UTI events being diagnosed in 10,091 women. Mean age was 56.9 years, and mean BMI was 29.1. The cohort underwent surgery for only SUI (35.4%), only POP (32.7%), or POP/SUI combined (31.9%). In the 13.5 months postoperatively, 11,976 UTIs were diagnosed in 6733 women. The first month experienced a sharp increase compared with the preoperative year, the second month increased further, and the third month showed leveling of PO-UTI incidence. Prescribed antibiotics captured most UTI events (13,337 or 58.3%). Prescribed antibiotics, in order of most-prescribed to least-prescribed, were as follows: ciprofloxacin (33.7%), cephalexin (21.4%), nitrofurantoin (20.4%), and sulfamethoxazole-trimethoprim (17.6%). The study determined that most PO-UTIs occurred within the first 2 months, with many of these being diagnosed within 2 weeks of surgery. For those patients already having a history of RUTI, RUTI significantly increases in postoperative year 1 when compared with the preoperative year. All patients undergoing SUI procedures had increased PO-RUTI risks compared with their POP-only group peers. Escherichia coli was the most common pathogen found. Risk and event timing were affected by surgical indication: although surgery for only SUI had a lower 6-week PO-UTI risk, it was counterintuitively associated with a higher PO-RUTI risk. Multivariate regression revealed predictable risk factors for PO-UTI: OAB, history of diabetes, history of preoperative UTI within 6 weeks of surgery, history of RUTI, stent and catheter placement. A more confusing finding was the association of a vaginal estrogen prescription with increased short-term PO-UTI risk, possibly related to its use in women with a history of RUTI, but more probably related to the postmenopausal status of many of the women in the dataset. The study recommends preoperative assessment with the purpose of identifying and eliminating UTIs within 6 weeks before surgery, as well as development of protocols for enhanced prophylaxis for women at increased risk such as diabetics and women with preoperative RUTI.