Surgery For Stress Incontinence Research Articles

Non-mesh stress incontinence surgery review: Bulking agents, autologous fascial slings and colposuspension

Increasing concerns over pelvic mesh procedures have resulted in a revival, development and modifications of older procedures. In this review we will discuss indications, procedure details, as well as risks and benefits of non-mesh alternative procedures. This review covers bulking agents, autologous fascial slings and colposuspension. Urethral bulking agent injections offers the lowest risk and quickest recovery, often performed with local anaesthetic in the out-patient setting, making it suitable even for the most frail and elderly patients.The evolution of technique in autologous fascial slings is described: from an obstructive continuous loop, to the current technique that is less invasive; with likely better safety profile. Graft can be harvested from the rectus sheath or the fascia lata. ‘Colposuspension’ constitutes of a constellation of retropubic urethropexy procedures that are technically different, in terms of approach,e.g. open/ laparoscopic, access, e.g. intra- or extra peritoneal, as well as suture placement characteristic to named techniques. The evidence on safety and efficacy presented in Cochrane reviews is summarised. The efficacy data from the randomised controlled trials comparing bulking agents, autologous fascial slings,and colposuspension techniques at long term follow up is discussed.

Outcomes of primary transobturator mid-urethral sling surgery in women of different ages

IntroductionOlder age is associated with greater likelihood of urinary incontinence and unmet care needs. It was hypothesized that age might influence clinical and ultrasound outcomes of transobturator mid-urethral sling (TOS) surgery. The aim of this study was to compare 1-year postoperative clinical and ultrasonographic outcomes of TOS surgery among women of different ages. MethodsA retrospective analysis of a cohort of women who underwent primary and isolated TOS surgery for uncomplicated urodynamic stress incontinence was undertaken. All women underwent pre-operative and 1-year postoperative evaluations including clinical interview, pelvic examination, urodynamic studies and introital four-dimensional ultrasound. To be eligible for surgery, women needed to be independent in their daily life, and to have an acceptable level of surgical risk on pre-operative assessment. The primary outcome was the rate of stress urinary incontinence (SUI) after surgery. The secondary outcomes comprised postoperative adverse events and ultrasound findings. ResultsIn total, 162, 213, 60 and 29 women aged <51, 51–64, 65–74 and ≥75 years, respectively, were included in this study. At 1-year postoperative assessment, older women were more likely to report SUI and bothersome SUI, while the severity of SUI and postoperative adverse events were similar in older women compared with other age groups. Ultrasound revealed that the sling tended to be looser and higher in older women. ConclusionTOS surgery is effective and safe for women of all ages who are independent in their daily life and who have an acceptable level of surgical risk. The sling tended to be looser and higher in older women.

The effect of stress incontinence and pelvic organ prolapse surgery on sexual function and quality of life.

The objective of this study was to evaluate the sexual function and quality of life in female patients diagnosed with stress urinary incontinence (SUI) and pelvic organ prolapse (POP) after undergoing transobturator tape (TOT) or TOT with POP surgery and perineoplasty. This prospective study population (n=86) consisted of sexually active women who had been diagnosed with SUI. Forty-six patients diagnosed with SUI with no POP (group 1) underwent TOT procedure only. Forty patients had a diagnosis of stage 2 and higher POP, based on POP quantification system with SUI (group 2). The second group was randomized as TOT-POP surgery (n=20) and TOT-POP surgery with perineoplasty (n=20). Prior to and six months after the surgical procedure, all female participants underwent assessment using the validated Urinary Distress Pre-Operative Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), and Pelvic Organ Prolapse Incontinence Sexual Questionnaire (PISQ). Post-operative IIQ-7 and UDI-6 scores were significantly lower for all three groups compared to the preoperative period, while a significant increase was observed in PISQ scores (p<0.01). The dissimilarity in preoperative and postoperative IIQ-7 and UDI-6 scores exhibited comparable results across the groups, whereas the variance in PISQ scores was notably greater in the TOT + POP surgery + perineoplasty group (p=0.03). Women with SUI or SUI with POP have better quality of life and sexual dysfunction after surgery. Perineoplasty may enhance sexual life in patients with perineal defect and vaginal enlargement.

Postoperative Complications After Sling Operations for Incontinence: Is Race a Factor?

Racial and ethnic disparities exist in urogynecologic surgery; however, literature identifying specific disparities after sling operations for stress incontinence are limited. The objective of this study was to evaluate racial and ethnic disparities in surgical complications within 30 days of midurethral sling operations. This retrospective cohort study identified women who underwent an isolated midurethral sling operation between 2014 and 2021 using the American College of Surgeons National Surgical Quality Improvement Program database. Women were stratified by racial and ethnic category to assess the primary outcome, 30-day surgical complications, and the secondary outcome, comparison of urinary tract infections (UTIs). There were 20,066 patients included. Mean age and body mass index were 53.9 years and 30.8, respectively. More Black or African American women had diabetes and hypertension, and more American Indian or Alaska Native women used tobacco. The only difference in 30-day complications was stroke/cerebrovascular accident, which occurred in only 1 Asian, Native Hawaiian or other Pacific Islander patient (0.1%, P < 0.0001). The most frequent complication was UTI (3.3%). Black or African American women were significantly less likely to have a diagnosis of UTI than non-Hispanic White (P = 0.04), Hispanic White (P = 0.03), and American Indian or Alaska Native women (P = 0.04). Surgical complications within 30 days of sling operations are rare. No clinically significant racial and ethnic differences in serious complications were observed. Urinary tract infection diagnoses were lower among Black or African American women than in non-Hispanic White, Hispanic White, and American Indian or Alaska Native women despite a greater comorbidity burden. No known biologic reason exists to explain lower UTI rates in this population; therefore, this finding may represent a disparity in diagnosis and treatment.

An in vitro pilot study investigating placenta-derived mesenchymal stem cell coating on polypropylene mesh materials.

Polypropylene meshes (PM) used in pelvic organ prolapse surgery are being withdrawn from the market. Although concerns about the usage of PMs in stress incontinence surgery have been raised, it is still one of the best methods of curing stress urinary incontinence. With advancements in stem cell-based therapies, especially mesenchymal stem cells (MSCs), it is believed that coating the synthetic meshes with MSCs may minimize excessive tissue reactions ultimately leading to clinical problems such as pain, erosion or extrusion of the implanted material. In our study we tried to show the possibility of coating the PM with placenta-derived MSCs. Mesenchymal stem cells obtained from six placentas were isolated, cultured, and identified. MSCs were then soaked in either fibronectin or collagen prior to co-culturing with strips of PMs. One group is used as a control, and hence was not pretreated before co-culturing. Specimens were fixed and stained with both Gram and hematoxylin and eosin and marked with Vybran Dil and DAPI. All preparations were examined under a light microscope. The IMAGEJ program was utilized to determine the surface area of meshes coated with MSCs. We clearly showed that PMs can be coated successfully with placenta-derived MSCs. The percentage of the coated area is significantly increased when meshes were pretreated with fibronectin or collagen (p<0.0001). Placenta-derived MSCs can successfully coat PMs. The immunomodulatory properties of MSCs, which may be of great advantage in preventing the side effects of meshes, should be tested by in vivo and hopefully human studies before clinical applications.

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.

MP37-01 HYSTERECTOMY FOR UTERINE FIBROIDS AND STRESS URINARY INCONTINENCE SURGERY: A NATIONWIDE COHORT STUDY

You have accessJournal of UrologyCME1 Apr 2023MP37-01 HYSTERECTOMY FOR UTERINE FIBROIDS AND STRESS URINARY INCONTINENCE SURGERY: A NATIONWIDE COHORT STUDY Jun Ho Lee Jun Ho LeeJun Ho Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003275.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Uterine fibroids (myomas or leiomyomas) are the most common benign uterine neoplasm. Hysterectomy is the most effective treatment for symptomatic uterine fibroids and uterine fibroids are currently the most common indication for hysterectomy worldwide. Previous studies investigated the relationship between the previous hysterectomy for benign conditions and subsequent stress urinary incontinence (SUI). However, the results are inconsistent across the studies. Additionally, long-term follow-up data from large data sets are lacking. Moreover, the impact of the previous hysterectomy for benign indication on subsequent surgery for SUI is scarcely investigated. METHODS: A retrospective cohort study was conducted on women aged 40 to 59 from the Korean Health Insurance Data 2010 to 2018. The hysterectomy group consisted of women who underwent hysterectomy for uterine leiomyoma and the control group consisted of women who visited a medical facility for a checkup between January, 2011 and December, 2014. Main outcome measures included the occurrence of stress incontinence surgery (R3564, R3565, R3562, R3563) with a urinary incontinence diagnosis code (N39.3, N39.4). For the selected hysterectomy group and control group, 1:1 propensity score matching was done on age at 5-year intervals, year at inclusion, socioeconomic status, parity, region, Charlson Comorbidity Index, adnexal surgery before inclusion, menopause before inclusion, menopausal hormone therapy, and pelvic organ prolapse before inclusion. RESULTS: After 1:1 propensity score matching, 81,373 cases and 81,373 controls were enrolled. The mean follow-up period was 7.9 years for cases and 7.8 years for control subjects. The rate of anti-incontinence surgery was significantly higher in the hysterectomy group compared to the non-hysterectomy group (1.7 vs. 2.0%; p<.001). As compared to the non-hysterectomy group, abdominal hysterectomy significantly increased anti-incontinence surgery before and after adjusting confounders (HR: 1.215; 95% CI: 1.097-1.347; p<.001). However, laparoscopic hysterectomy, laparoscopic hysterectomy with adnexal surgery, and abdominal hysterectomy with adnexal surgery did not increase anti-incontinence surgery as compared to the non-hysterectomy group before and after adjusting confounders. This significant relationship between abdominal hysterectomy and anti-incontinence surgery was maintained after stratifying patients according to age group. CONCLUSIONS: In conclusion, hysterectomy, especially transabdominal hysterectomy significantly increases the risk of subsequent anti-incontinence surgery. Our data suggest that patients who plan to undergo transabdominal hysterectomy for the treatment of uterine fibroids should know and be counseled about the risk of SUI and especially the risk of anti-incontinence surgery. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e513 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jun Ho Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

Reoperation rates of stress incontinence surgery in rural vs urban hospitals

BACKGROUNDXXX.OBJECTIVEThis study aimed to determine the impact of a rural vs urban hospital location on the risk of undergoing a second surgery for stress urinary incontinence.STUDY DESIGNUsing the Cerner Health Facts nationwide electronic medical record database, we identified patients who underwent surgeries for stress incontinence between January 1, 2010 and November 30, 2018. Stress incontinence surgeries included synthetic midurethral slings, fascial slings, retropubic urethral suspension, and other surgeries for stress urinary incontinence, such as the laparoscopic sling or the Pereyra procedure. Patients were divided into 2 cohorts, namely those who had a single operation and those who had a reoperation, defined as any second stress incontinence surgery or revision after initial incontinence surgery. Logistic regression analysis was performed to determine whether urban vs rural hospital location impacted reoperation rates. We adjusted for significant sociodemographic variables identified in the univariate analysis with a P value <.1.RESULTSOf the 25,085 women who underwent stress incontinence procedures, 669 (2.7%) underwent a second surgery. Of these, 346 (51.7%) patients underwent were a second stress incontinence procedure, 307 (45.9%) underwent revisions of the index case, and 16 (2.4%) underwent both. Women in the single surgery cohort were older (median age, 54 vs 53 years; P=.029). In the total sample, 85.5% identified as White and 4.5% identified as Black. Of the study cohort, 7720 (30.8%) had obesity and 2660 (10.6%) had diabetes. There was a higher rate of reoperation among patients with obesity (3.0% vs 2.5%; P=.017). Among patients who underwent a concomitant prolapse surgery with their index surgery, there were fewer reoperations (2.2% vs 2.8%; P=.012). In the univariate analysis, we did not detect a difference between women who lived in rural vs urban areas (3.0% vs 2.6%; P=.16). After adjusting for confounders, we still did not see a significant association between rural hospital location and the risk for repeat surgery (odds ratio, 1.00; 95% confidence interval, 0.76–1.31). In this multivariable regression, obesity increased the risk for having a reoperation (odds ratio, 1.20; 95% confidence interval, 1.02–1.41), whereas patients who had concomitant prolapse procedures with their index surgery had a reduced risk for having a reoperation (odds ratio, 0.80; 95% confidence interval, 0.66–0.98).CONCLUSIONWe did not detect an association between hospital location (rural vs urban) and the risk for reoperation among women undergoing stress incontinence surgery. With low reoperation rates, patients can be reassured that they are receiving excellent care in either setting.

Risk of reoperation 10 years after surgical treatment for stress urinary incontinence: a national population-based cohort study

There is a debate about the safety and effectiveness of surgical treatments for stress urinary incontinence. Controversy about the use of synthetic mesh sling insertion has led to an increased uptake of retropubic colposuspension and autologous sling procedures. Comparative evidence on the long-term outcomes from these procedures is needed. To compare the risk of reoperation at 10 years after operation between women treated for stress urinary incontinence with retropubic colposuspension, mesh sling insertion, and autologous sling procedures. The records of admissions to National Health Service hosptials were used to identify women who had first-time stress incontinence surgery between 2006 and 2013 in England. The first incidence of the following outcomes was assessed: further stress incontinence surgery, surgery for a complication (either mesh removal, prolapse repair, or incisional hernia repair), and any reoperation (either further stress incontinence surgery, mesh removal, prolapse repair, or incisional hernia repair). The cumulative incidence of each of these outcomes up to 10 years after surgery was calculated, considering death as a competing event. Multivariable modeling was then used to estimate the reoperation hazard ratios for the different initial surgery types with adjustments for patient characteristics and concurrent prolapse surgery or hysterectomy. The analysis included 2262 women treated with retropubic colposuspension, 92,524 treated with mesh sling insertion, and 1234 treated with autologous sling. The cumulative incidence of any first reoperation at 10 years was 21.3% (95% confidence interval, 19.5-23.0) after retropubic colposuspension, 10.9% (10.7-11.1) after mesh sling insertion, and 12.0% (10.2-13.9) after autologous sling procedures. The women who had a retropubic colposuspension were significantly more likely to have a reoperation than women who had an autologous sling (adjusted hazard ratio for any reoperation: 1.79 [1.47-2.17]; for further stress incontinence surgery: 1.64 [1.19-2.26]; for surgery for complications: 1.89 [1.49-2.40]), whereas the women who had mesh slings had a similar hazard (for any reoperation: 0.90 [0.76-1.07]; for further stress incontinence surgery: 0.75 [0.57-0.99]; for surgery for complications: 1.11 [0.89-1.36]). A sensitivity analysis excluding the women who had concurrent prolapse surgery or hysterectomy produced similar results. Retropubic colposuspension is associated with higher risk of reoperation at 10 years after surgery than mesh sling insertion or autologous sling procedures, with 1 in 5 women requiring reoperation.

Surgical treatment of female stress incontinence: impact of changed views on polypropylene

AbstractThe introduction of the tensionfree vaginal tape in 1995 drastically changed the landscape of surgical procedures for stress urinary incontinence (SUI). Because of the uncomplicated technique many urologists and gynecologists embraced the procedure with tripled the number of annual procedures in the beginning of this century. At the same time polypropylene was used for the development of surgical procedures of pelvic organ prolapse (POP). Especially the use of polypropylene for POP has caused many severe clinical complications. This caused a huge reduction of these kind of surgical procedures and it is performed nowadays only under strict conditions. At the same time the use of polypropylene for SUI was scrutinized and questioned. Nowadays, in the Ango-Saxon countries the use of polypropylene tapes for SUI is not recommended. This manuscript explores the role of polypropylene tapes for SUI. Questions that are dealt with are: How dangerous are polypropylene tapes anyway? What are the alternatives? Which factors contribute to a successful outcome of stress incontinence surgery?

MP17-08 RELATIVE VALUE UNITS AND OPERATION TIME IN UROLOGY

You have accessJournal of UrologyHealth Services Research: Value of Care: Cost and Outcomes Measures I (MP17)1 Sep 2021MP17-08 RELATIVE VALUE UNITS AND OPERATION TIME IN UROLOGY Joshua Cadwell, Salma Ahsanuddin, Mubashir Billah, Courtney Berg, and Robert Weiss Joshua CadwellJoshua Cadwell More articles by this author , Salma AhsanuddinSalma Ahsanuddin More articles by this author , Mubashir BillahMubashir Billah More articles by this author , Courtney BergCourtney Berg More articles by this author , and Robert WeissRobert Weiss More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002002.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Many academic and private practice clinical urology groups are basing salaries on relative value units (RVUs). This study analyzes the relationship between operation time, complication rate, and RVUs in urology. METHODS: The 2015-2018 National Surgical Quality Improvement Program was queried for all cases with assigned RVUs, a nonzero operation time, and urology as the primary service. Cases with concurrent procedures were excluded. Only the top 50 CPT codes were included in analysis. The median operation time, assigned RVUs, and proportion of postoperative complications, including unplanned return to the operating room or readmission, or wound and medical complications were found for each CPT. Linear regressions were completed between these aforementioned variables. Expected RVUs were calculated from the regression between operation time and assigned RVUs. RESULTS: 143,118 cases were included in the analysis. The median assigned RVUs was 15.26, operation time was 67 minutes, and RVUs per hour was 13.7. RVUs ranged from 5.2 to 26.0 and the rate of any postoperative complication ranged from 0.8% to 63.9%. There was a strong linear correlation between RVUs and median operation time (R2=0.95, p <0.001). Each additional procedural hour was associated with an increase of 7.5 RVUs. The procedures with the largest positive deviation from expected included sling operation for stress incontinence and transurethral electrosurgical resection of the prostate, at 185.0% and 162.0% of expected, respectively. Procedures with the largest negative deviation from expected were drainage of a scrotal wall abscess and open varicocelectomy, at 49.8% and 50.8% of expected, respectively. There were moderately positive associations between complications and operation time (R2=0.65, p <0.001), as well as complications and assigned RVUs (R2=0.59, p <0.001). There was a minimal correlation between complication rate and RVUs per hour (R2=0.10, p=0.023). CONCLUSIONS: This study shows that RVUs and operation time are strongly correlated in urology, thus confirming the relevance of using RVUs for clinical compensation. Source of Funding: Not applicable © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e310-e311 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joshua Cadwell More articles by this author Salma Ahsanuddin More articles by this author Mubashir Billah More articles by this author Courtney Berg More articles by this author Robert Weiss More articles by this author Expand All Advertisement Loading ...

Evaluation of Female Patient Satisfaction after Midurethral Sling Surgery for Stress Urinary Incontinence

Background: Stress Urinary incontinence (SUI) is a public health condition that affects women worldwide, Patient satisfaction after stress incontinence surgery is influenced by many factors, patient-specific expectations, postoperative continence status, and complications. Traditionally treatment success has been defined by cure rate and symptom improvement, patient-reported outcomes, particularly satisfaction, have been recognized as complementary measures of success, This study amid to evaluate patient satisfaction post sling surgery for stress urinary incontinence. Methods: It is a retrospective study including 30 female patients, 15 underwent Transobturator Vaginal Tape (TOT) operation and 15 underwent Tension-free vaginal tape (TVT) for stress urinary incontinence between Jan 2019 to Jan 2020 in Urology Department, Faculty of Medicine, Zagazig University. Patients were evaluated 12 month post MUS for complications and satisfactions by(ICIQ-SF) score, quality of life score , female sexual function index, and Global response assessment scale.Results: Marked improvement in International consultation on incontinence Questionnaire –Short Form and quality of life (ICIQ-SF) score dropped from (12.20±2.27) to (1.40±0.51) TOT group and from (11.26±2.15) to (1.06±0.23) in TVT group. The Quality of life score improved by dropping from (5.26±1.22) to (0.48±0.11) and from (5.06±1.09) to (0.51±0.11) in TVT group with no significant difference between both groups. All items of (FSFI) score were improved from pre to post-management without difference between both groups. Conclusions: Mid urethral slings have high patient satisfaction rates regarding the improvements in ICIQ-SF scores and FSFI on short-term and are relatively safe procedures

P0111 - Perioperative use of anticholinergic medication in patients undergoing surgery for male urinary stress incontinence

P0111 - Perioperative use of anticholinergic medication in patients undergoing surgery for male urinary stress incontinence

P0110 - Membranous urethral length (MUL) in patients who have had male sling or artificial urinary sphincter surgery for bothersome post prostatectomy stress incontinence

P0110 - Membranous urethral length (MUL) in patients who have had male sling or artificial urinary sphincter surgery for bothersome post prostatectomy stress incontinence

50 Reoperation rates of stress incontinence surgery in rural versus urban hospitals

To determine the impact of a rural versus urban hospital location on the risk of having a second surgery for stress urinary incontinence. Using the Cerner Health Facts nationwide electronic medical record database, we identified patients who underwent surgeries for stress incontinence between 01/01/2010 and 11/30/2018. Patients were divided into two cohorts: those who had a single operation and those who received a repeat operation, defined as any stress incontinence surgery or revision after initial incontinence surgery. Logistic regression was performed to determine whether urban versus rural hospital location impacted reoperation rates. We adjusted for confounders including sociodemographic variables with P<0.1 on univariable analysis. Of the 25,085 women who underwent stress incontinence procedures, 669 (2.7%) underwent a second surgery. The median age was 54 (IQR=45-66). 85.5% identified as white and 4.5% identified as black. 7,720 (30.8%) were obese and 2,660 (10.6%) had diabetes. There was a higher rate of repeat stress incontinence procedures in patients who were obese (3.0% vs 2.5%, P=0.017). In patients who underwent concomitant apical prolapse procedures with their index surgery, there were fewer repeat surgeries (2.2% vs 2.8%, P=0.012). On univariable analysis, we did not detect a difference between women who lived in rural vs. urban areas (OR=1.16, 95%CI=0.94-1.43). After adjusting for confounders, we still did not see a significant difference between rural hospital location and risk of repeat surgery (OR=0.99, 95%CI=0.99-1.00). Obesity increased the risk of having a repeat surgery (OR=1.21) while patients who had concomitant prolapse procedures with their index surgery had reduced risk of having a repeat surgery (OR=0.79). A summary of the full regression is displayed in Table 1. We did not detect a difference in rural versus urban hospital location on the risk of reoperation for women undergoing stress incontinence surgery. Patients who were obese were more likely to have a repeat surgery while patients with concomitant incontinence were less likely to undergo reoperation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

51 Urethral mesh exposure of transobturator tape: Cystolithopaxy of urethral calculus and transurethral mesh excision

The objective of this video is to demonstrate a dual modality technique for the removal of transurethral mesh exposure with an overlying obstructive urethral calculus using a transurethral Holmium laser and a transurethral and transvaginal approach to mesh dissection. A 55-year-old patient presented to our Female Pelvic Medicine and Reconstructive Surgery (FPMRS) clinic complaining of worsening mixed urinary incontinence, recurrent urinary tract infection and pelvic pain over the past four months. She had a history of trans obturator mid-urethral sling placed at an outside hospital in 2004. Office cystourethroscopy demonstrated an approximately 1 cm urethral calculus overlying a transurethral mesh exposure extending across the anterior urethral wall. A two-step surgical plan was made. The first procedure included cystolithopaxy of the urethral calculus. The second surgery included a transurethral and transvaginal resection of the trans obturator sling and exposed urethral mesh, as well as placement of an autologous rectus fascial sling for the patient’s ongoing stress urinary incontinence. Both surgeries are presented in this video. Mesh exposure is a rare complication of surgery for stress incontinence with mid-urethral sling; however, it is important that FPMRS providers are equipped with the surgical techniques for safe and effective removal. This video serves to educate the gynecologic community on one approach to successful surgical removal of a complicated urethral mesh exposure.

Falling in the margin: Randomised controlled trials with a non-inferiority design.

In a randomised controlled trial (RCT) we are usually trying to answer the question of which treatment is best. Sometimes, though, we may be considering a treatment that we do not believe will perform better than an existing option but has other benefits: it could be cheaper, easier to deliver or more acceptable to patients. For example, the need for urodynamic testing compared with simple office evaluation before stress incontinence surgery was evaluated in an RCT (Nager et al. N Engl J Med 2012;366:1987–97). The authors believed that simple office-based evaluation would be less invasive than urodynamic testing and that it may also reduce the risk of urinary tract infections. It was also expected that simple office-based evaluation was unlikely to reduce treatment success. The key consideration is how much worse in terms of outcome is going to be acceptable. There is no consensus about how this should be evaluated, but intuitively the difference should be small and should take into account the nature of the outcome, balanced with the potential benefits. One option is to ask clinicians and patients what level of difference would cause them to switch treatments. This level is termed a non-inferiority margin and determines the size of the trial. Confidence intervals are used to determine whether a new treatment is ‘not unacceptably worse’ than a standard treatment. If the upper end of the confidence interval (CI) for the treatment effect is smaller than the non-inferiority margin, then we can conclude non-inferiority (scenario B in Figure 1). A number of other design issues should be considered in this setting and may be why some consider non-inferiority trials to have more weaknesses than superiority trials. These include: (i) ensuring that the efficacy of the standard comparator has been proven on a similar population; (ii) selecting an appropriate analysis population in light of a reverse hypothesis (i.e. in trying to demonstrate similarity, per-protocol populations could be considered alongside intention-to-treat populations); and (iii) taking care with trial conduct, as carelessness (such as poorly executed randomisation) may lend itself to the conclusion of similarity. Further reading on these issues is recommended (see below). The primary outcome in the study described above was treatment success (i.e. symptoms that have substantially improved) at 12 months. The non-inferiority margin was set at 11 percentage points. The study found that in patients tested with urodynamics the treatment success rate was 76.9% (203/264), and for patients undergoing simple office evaluation the treatment success rate was 77.2% (200/259). The percentage difference between the two groups was –0.3% (95% CI –7.5% to 6.9%). This confidence interval tells us that office-based evaluation might be as much as 6.9% worse (upper end of CI) or as much as 7.5% better (lower end of CI) than evaluation with urodynamics. The results therefore indicated that office evaluation is certainly less than 11% worse. The authors declared non-inferiority, recommending that urodynamics need not be performed. 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.

Comparison of Long-term Effect and Complications Between Holmium Laser Enucleation and Transurethral Resection of Prostate: Nations-Wide Health Insurance Study

ObjectiveTo investigate and compare the postoperative efficacy and complications of the transurethral resection of prostate (TURP) and holmium laser enucleation (HoLEP) using the nationwide insurance database of Korea. MethodsWe created a cohort of benign prostatic hyperplasia (BPH) patients treated with TURP and HoLEP between 2011 and 2017 from the nationwide database of reimbursement. We compared the postoperative effects between the two surgical groups. ResultsWe retrieved a total of 58,346 patients (TURP 38,308 and HoLEP 20,038 patients). The mean follow-up duration was 51.6 and 47.6 months, respectively. The rate of reoperation was significantly higher in the TURP group (4.50%) than in the HoLEP group (1.27%) (P < .01). The postoperative use of alpha-blockers and dutasteride/finasteride was significantly higher in the TURP group until 24 months postoperatively. The rate of the postoperative use of medications for symptoms of overactive bladder was lower in the TURP group than in the HoLEP group until 12 months postoperatively, but it did not differ after 12 months postoperatively. Overall, urethral surgeries were less frequently performed in the TURP group than in the HoLEP group (P < .05); however, more severe cases required surgeries under general anesthesia in the TURP group (P < .05). Postoperative surgery for stress incontinence was performed in 0.10% and 0.31% of patients after TURP and HoLEP, respectively (P < .01). ConclusionThis study showed the superiority of HoLEP compared to TURP in terms of postoperative efficacy and its inferiority in terms of complications of stress incontinence in real life practice.

Stress Incontinence Surgery Does Not Cause Pelvic Malignancy: A Population-Based Cohort Study

We sought to determine if stress urinary incontinence surgery (mesh or nonmesh) is associated with the development of pelvic malignancies later in life. We performed a retrospective cohort study between January 1, 2002 and October 31, 2015 of all women in Ontario, Canada without a history of pelvic malignancy who underwent an index stress incontinence surgery. The primary outcome was a composite of any pelvic malignancy (including urological and gynecological cancers) following stress incontinence surgery. Secondarily, we considered each cancer individually. A survival analysis using a Cox proportional-hazards model with a 3-level categorical exposure (mesh surgery, nonmesh surgery, and control) was performed. Patients were followed until death, emigration or the study end (October 31, 2017). Of the women 74,968 underwent stress urinary incontinence surgery during the study period. There were 5,505,576 women in the control group. Over a median followup of 8.5 years (IQR, 5.5-11.9), 587 pelvic malignancies occurred in the surgery group. Women who underwent stress incontinence surgery had a reduced risk of pelvic malignancy independent of surgery type, compared to controls (Wald type 3 p <0.001; mesh HR, 0.68 [95% CI, 0.62-0.76]; p <0.0001; nonmesh HR, 0.37 [95% CI, 0.29-0.46]; p <0.0001). The individual pelvic cancers similarly demonstrated a reduced risk of malignancy following stress incontinence surgery. At a median followup of 8.5 years, women had no increased risk of pelvic malignancy following either mesh or nonmesh stress urinary incontinence surgery in a large population-based cohort.

The Impact of Frailty on Outcomes of Sling Surgery with and without Prolapse Repair.

Frailty has emerged as a significant predictor of morbidity in urological surgery, but its impact on outcomes of sling surgery for stress incontinence remains unclear. The purpose of this study is to describe the prevalence of frailty among women undergoing sling surgery and determine the association of frailty with 30-day postoperative outcomes. We analyzed data from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP®) in 2013-2016 to identify patients undergoing sling placement using Current Procedural Terminology, 10th edition, code 57288. Patients were categorized into 2 groups based on whether they underwent isolated sling placement or had a sling with concomitant prolapse surgery. Frailty was assessed using the 5-factor Modified Frailty Index (mFI-5) developed for use with the NSQIP data set. Patients were considered frail if 2 or more factors from the mFI-5 were present. Outcomes and complications within 30 days were captured from the NSQIP data and logistic regression models used to adjust for age, race/ethnicity, body mass index and frailty. We identified 25,887 women who underwent sling placement, 15,087 of whom underwent isolated sling placement (Group 1) and 10,800 of whom underwent sling with concomitant prolapse repair surgery (Group 2). Frailty was present in 9.3% of patients in Group 1 and 10.2% of patients in Group 2 (p=0.0122). Among those who underwent isolated sling placement, frailty was associated with increased length of hospital stay (OR 1.2, 95% CI 1.1-1.4, p=0.0008) and 30-day hospital readmission (OR 1.7, 95% CI 1.1-2.5, p=0.0093). Older patients undergoing isolated sling placement were more likely to have longer operation time (OR 1.2, 95% CI 1.1-1.3, p <0.0001) and hospital length of stay (OR 1.3, 95% CI 1.2-1.4, p <0.0001). Frailty was also associated with increased 30-day hospital readmission in patients who underwent sling with concomitant prolapse repair (OR 1.8, 95% CI 1.3-2.6, p=0.0003), while age was not (OR 0.9, 95% CI 0.7-1.1, p=0.29). We found that frailty was present in relatively few patients undergoing sling surgery. Adverse postoperative outcomes and complications were low overall. Increased age and frailty were both associated with longer length of stay. Frailty, but not age, was significantly associated with increased likelihood of hospital readmission within 30 days following surgery. Our findings provide insight into the preoperative characteristics of women undergoing sling surgery in a large national sample, suggesting the need for preoperative identification of the frail patient.