Transobturator Sling Research Articles

A New Quadratic Sling for Male Stress Incontinence: Retrograde Leak Point Pressure as a Measure of Urethral Resistance

Objective methods are essential for evaluating post-prostatectomy incontinence. While symptom score and pad weight may be the most useful methods to evaluate preoperative vs postoperative continence, neither is useful for guiding intraoperative sling tension. The Virtue quadratic sling (Coloplast, Humlebaek, Denmark) is a new device for treating post-prostatectomy incontinence that combines a transobturator and prepubic surgical approach. We examined urethral resistance by measuring retrograde leak point pressure during key portions of the surgery. A total of 22 consecutive men who elected to undergo Virtue sling surgery were evaluated with retrograde leak point pressure before and during the surgery. Retrograde leak point pressure was measured via perfusion sphincterometry at baseline, after transobturator tensioning, after prepubic tensioning, and after transobturator and prepubic arms were secured in place. Mean patient age was 70 years. Mean baseline retrograde leak point pressure was 33.4 ± 8.8 cm water. After transobturator tensioning, mean retrograde leak point pressure increased to 43.3 ± 6.8 cm water. After prepubic tensioning mean retrograde leak point pressure was 55.8 ± 8.7, and final retrograde leak point pressure after transobturator and prepubic fixation increased to 68.8 ± 6.0 cm water. Each mean retrograde leak point pressure value was significantly higher than the preceding value. The Virtue sling provides ventral urethral elevation using a transobturator approach, and a long segment of urethral compression against the genitourinary diaphragm via a straightforward prepubic technique without the risks of bone screws or retropubic needle passage. Transobturator and prepubic components of the quadratic fixation contributed to increasing urethral resistance as measured by intraoperative retrograde leak point pressure. This quadratic technique has a potentially greater ability to provide urethral compression than does a purely perineal or transobturator sling.

Intraoperative maximal urethral closing pressure measurement: a new technique of tape tension adjustment in transobturator sling surgery?

Tape tension adjustment is an essential procedure in mid-urethral sling surgery. The goal of this study was to determine if intraoperative maximal urethral closing pressure (MUCP) elevation could be used as a reference value for adequate tape tension adjustment and predict transobturator (TOT) sling surgery outcome. A prospective study was performed using MUCP measurements just before tape insertion and just after tension adjustment during surgery. Clinical data including preoperative urodynamic results were collected. The cure rate was determined by questionnaire. Patients were divided into two groups. The MUCP elevation group included patients with a MUCP elevation of more than 10 cmH(2)O before tape insertion; the others were regarded as the non-elevation group. The cure rate and pre- and postoperative clinical variables were compared between the two groups. A total of 48 patients had TOT surgery. The MUCP elevation group (n = 19) and the non-elevation group (n = 29) were similar with regard to patient characteristics and the preoperative parameters including age, mixed incontinence prevalence, Q-tip angle, peak flow rate, MUCP and the valsalva leak point pressure (VLPP). The mean follow-up period was nine months. The cure rate was significantly higher in the group with MUCP elevation than in the non-elevation group (84% vs. 52%, p = 0.02). There was no significant difference in the mean postoperative peak flow rate between the two groups and there was no retention episode. MUCP elevation of more than 10 cmH(2)O just after tape insertion was a prognostic factor.

The Inside-Out Transobturator Male Sling for the Surgical Treatment of Stress Urinary Incontinence After Radical Prostatectomy: Midterm Results of a Single-Center Prospective Study

BackgroundTransobturator slings are currently promoted for the treatment of stress urinary incontinence (SUI) after radical prostatectomy (RP), but data on outcome remain limited. ObjectiveTo assess, at midterm, the efficacy and safety of the inside-out transobturator male sling for treating post-RP SUI and to determine factors associated with failure. Design, setting, and participantsProspective one-center trial involving 173 consecutive patients without detrusor overactivity, treated between 2006 and 2011 for SUI following RP. InterventionPlacement of an inside-out transobturator sling. MeasurementsBaseline and follow-up evaluations included uroflowmetry and continence and quality-of-life (QoL) questionnaires. Cure was defined as no pad use and improvement as a number of pads per day reduced by ≥50% and two or fewer pads. Complications were recorded, and factors associated with treatment failure were evaluated. Results and limitationsPreoperatively, 21%, 35%, and 44% of the patients were using two, three to five, and more than five pads per day, respectively. After a median follow-up of 24 mo (range: 12–60 mo), 49% were cured, 35% improved, and 16% not improved. QoL was enhanced (p<0.001), and 72% of patients were moderately to completely satisfied with the procedure. Maximum flow rates were slightly reduced (p=0.004); postvoid residual volumes were similar (p=0.097). Complications were urinary retention after catheter removal (15%), perineal/scrotal hematoma (9%), pain lasting >6 mo (3%), and sling infection (2%); all were managed conservatively. Severe SUI before sling surgery was not associated with a worse outcome, whereas obesity and a history of pelvic irradiation or bladder neck stenosis were independent risk factors of failure, with risk ratios of 7.9 (95% confidence interval [CI], 3.3–18.9), 3.3 (95% CI, 1.4–7.8), and 2.6 (95% CI, 1.1–6.5), respectively. ConclusionsThe inside-out transobturator male sling is an efficient and safe treatment for post-RP SUI at midterm. Patients with prior pelvic irradiation may not be suitable candidates.

The male sling for post‐prostatectomy urinary incontinence: a review of contemporary sling designs and outcomes

To examine the outcomes and adverse events associated with novel male sling designs described in the last decade. A literature review was carried out using Medline, EmBase, Cochrane Registered Trials Database and the Center for Reviews and Dissemination Database. Three principal slings are described in the literature. The bone-anchored sling has success rates of 40-88%, with some series having a mean follow-up of 36-48 months. It is associated with a mesh infection rate of 2-12%, which usually requires sling explantation. The retrourethral transobturator sling has a success rate of 76-91% among three large case series with follow-ups of 12-27 months. There is a low reported explantation rate. The adjustable retropubic sling has a success rate of 72-79% with follow-ups of 26-45 months. Erosion (3-13%) and infection (3-11%) can lead to explantation. Most male slings have a similar reported efficacy. Most case series define success as either dry or improved. True cure rates are lower. Mid- and long-term data are now available that indicate the male sling is a viable option for PPI. The use of male slings in severe UI, radiated patients, and non-radical prostatectomy patients is still unclear. Further study is needed to try and define criteria for the use of male slings, and to directly compare different procedures.

Transobturator vs. Single Incision Sling in Women with Stress Urinary Incontinence: A Prospective Randomized Controlled Trial

Transobturator vs. Single Incision Sling in Women with Stress Urinary Incontinence: A Prospective Randomized Controlled Trial

UP-03.168 Long-Term Follow-Up of Argus T® (Adjustable Transobturator Sling) for the Treatment of Post-Radical Prostatectomy Urinary Incontinence (PRPUI)

Slings have been used for the treatment of PRPUI in many people. It may represent a cheaper and simpler option to the artificial sphincter. Although the sling results were good in short term follow-ups, many patients presented recurrence of incontinence after some months. Adjustable slings permit postoperative adjustments and the recovery of continence. Additionally the transobturator approach avoids bladder perforation. We investigated the efficacy and safety of a transobturator adjustable sling to treat PRPUI.

VID-02.05 Adjustable Transobturator Sling (Argus T®) for the Treatment of Post Radical Prostatectomy Urinary Incontinence (PRPUI)

VID-02.05 Adjustable Transobturator Sling (Argus T®) for the Treatment of Post Radical Prostatectomy Urinary Incontinence (PRPUI)

UP-01.071 Surgical Management of the Complications Associated with Transobturator Sling Procedures

The transobturator tape procedure (TOT) is an effective surgical treatment of female stress urinary incontinence. The aim of this study was to describe complications associated with TOT procedures and means to surgically solve complications like erosions and injuries (perforation).

Editorial Comment

Editorial Comment

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

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

Single institution experience with the transobturator sling suspension system AdVance® in the treatment of male urinary incontinence: mid-term results

To evaluate the clinical outcome after placement of AdVance® sling in men with stress urinary incontinence after prostate surgery. Incontinence was assessed on basis of number of pad usage. Patients' satisfaction was evaluated using a non-validated patient questionnaire at 12 months post-operatively. Incontinence cure rate (no pad usage) was 61.5% (16/26) and improvement (1-2 pads per day) was seen in 26.9% (7/26). No improvement was observed in 11.5% (3/26) of patients. A total of 87.5% (21/24) of patients were very satisfied with the operation 22 months after surgery. Success rate in patients with prior radiation therapy (20% cure; 40% improvement) was significantly worse. Placement of the AdVance® sling represents an effective and safe treatment option for patients with post prostate surgery incontinence. Patients that underwent radiotherapy after prostate surgery had lower success rate.

Urodynamic Parameters After Retrourethral Transobturator Male Sling and Their Influence on Outcome

To evaluate prospectively detailed urodynamic parameters before and after retrourethral transobturator sling (RTS) placement and the impact of adverse preoperative urodynamic parameters on postoperative outcome. Fifty-five consecutive patients with postprostatectomy stress urinary incontinence (SUI) underwent urodynamics with pressure flow and abdominal leak point pressure (ALPP) measurements, quality of life, 1-hour pad test, and daily pad use assessment before RTS (AdVance) and 12 months postoperatively. Volume of first sensation and first desire to void, maximum cystometric capacity (MCC), ALPP, maximum flow rate (Qmax.), average flow rate, time to Qmax., detrusor voiding pressure at Qmax., voiding time, and postvoid residual urine volume (PVR) were assessed. The success rate was defined as cure (no or one dry "security" pad) or improvement (1-2 pads or pad reduction≥50%). Adverse parameters included ALPP≤30 cm H2O, Qmax.≤10 mdL/s, and MCC≤200 mL. Success rate after RTS was 73% (40/55 patients). Mean follow-up was 21±11.7 (range, 12-41) months. Only ALPP changed significantly (61±14.2 vs 79±20.4 cm H2O). No PVR>30 mL, de novo reduced bladder compliance and hypo- or overactivity were observed. Urine loss by 1-hour pad test (136.1±119.4 vs 39.4±77.0) and daily pad use (4.6±2.0 vs 1.9±2.1) decreased significantly. Adverse preoperative urodynamic parameters were not associated with postoperative outcome. The RTS is an effective and safe device for SUI treatment without signs of compression or obstruction of the urethra or any influence on voiding parameters. Adverse preoperative urodynamic parameters have no influence on postoperative outcome.

Consecutive vesicovaginal fistula for transobturator sling perforations and successful repairs with skin flap

To report a reconstructive technique of large vesicovaginal fistula repairs, which is a rare complication of the most modern anti-incontinence procedures (tension-free tapes) using the "oldie but goodie" Lehoczky's island flap. Women with large vesicovaginal fistulas caused by mid-urethral transobturator tape were operated in our department. The transobturator tape was removed and the large fistula was closed using the skin island flap. The flap was created from the regional skin and subcutaneous tissue and pulled with intact vascular supply through a paravaginal tunnel to the site of the vaginal defect. No complications occurred after the reconstructions. The patients have become permanently continent and free from fistulas. Mid-urethral transobturator sling is a successful procedure evidenced worldwide with a very low rate of fistula formation. Lehoczky's island flap can be a reasonable and safe surgical option in the repair of large defects of the vaginal wall.

Tape Fixation: An Important Surgical Step to Improve Success Rate of Anti-Incontinence Surgery

Mid urethral slings are effective surgical treatment for stress urinary incontinence. However, 5% to 20% of patients still experience surgical failure with clinically significant recurrent or persistent stress urinary incontinence. Since a subset of these failures may be caused by improper tape position, we elucidated whether additional paraurethral fixation of a tape to prevent displacement during tensioning could improve the transobturator sling outcome. The study was done in 463 patients with stress urinary incontinence who were randomly allocated to treatment with a standard transobturator intravaginal monofilament sling procedure (232) or to an intravaginal transobturator monofilament sling with additional 2-point tape fixation (231). Another 2 absorbable sutures parallel to the urethra were added to fix the tape and prevent displacement during tape tensioning. Outcome was assessed by a cough test and a 1-hour pad test at 12 months. Clinical efficacy of the procedure with fixation was significantly higher with 195 women (95.12%) cured or improved compared to the 199 (88.73%) cured or improved with the standard sling (chi-square 5.71, p = 0.0169). There was no increase in intraoperative or postoperative complications. Also, among patients with intrinsic sphincter deficiency we noted a significantly better outcome in the fixation group than in the control group, that is 39 of 41 patients (95.1%) cured or improved vs 31 of 42 (73.8%) (chi-square 10.65, p = 0.0011). Tape fixation significantly increases the clinical efficacy of the transobturator sling, especially in patients with intrinsic sphincter deficiency.

The AdVance ® Male Sling: Patient Selection and Workup

The AdVance ® male sling (American Medical Systems, Minnetonka, MN, USA) is a retrourethral transobturator sling that offers an effective surgical approach for the treatment of postprostatectomy stress urinary incontinence (SUI). Clinical studies have demonstrated success rates of 80–90% at 1-yr follow-up. The most appropriate candidate patients for the AdVance ® sling may be those with mild to moderate incontinence, but success rates may not be markedly lower in patients with severe incontinence. Clinical experience with the AdVance ® sling suggests that cystoscopically confirmed residual sphincter function is an important requirement for good outcome. Assessment of SUI should be modified to include a consideration of sphincter function in addition to the currently accepted definitions of incontinence severity (pad weight and number). The AdVance ® male sling may be considered a first-line surgical treatment as well as a salvage treatment for some patients who have failed previous surgical treatment. More data are needed to better understand the patient-related factors that affect the short- and long-term outcomes of this minimally invasive treatment for male SUI.

AdVance ® Male Sling: Surgical Technique and Postoperative Patient Management

The AdVance ® transobturator sling, an innovative sling developed to correct postprostatectomy stress urinary incontinence, acts by repositioning the urethral sphincter complex back into the pelvis. Optimal placement of the sling on the urethral bulb is ensured by following a recommended surgical technique. Postoperative pain resolves spontaneously or is easily controlled with analgesics. Patients must comply with postoperative care instructions, that is, no strenuous exercise in the immediate postoperative period to avoid sling slippage. It is also feasible to conduct implantation of an inflatable penile prosthesis in men with erectile dysfunction at the same time as the AdVance ® sling. The subsequent placement of an artificial urinary sphincter is not compromised in men who have previously received the AdVance ® sling.

Clinical Overview of the AdVance ® Male Sling in Postprostatectomy Incontinence

Context Postprostatectomy stress incontinence can be treated with a number of nonsurgical and surgical methods. Urethral slings represent one of the less invasive surgical options, and a more recent addition to this class of devices is the nonobstructive transobturator sling, the AdVance ® male sling. We provide a review of the clinical outcomes with this sling. Objective To evaluate the literature on published clinical studies on the AdVance ® sling in treating postprostatectomy incontinence. Evidence acquisition We searched the PubMed database and evaluated all clinical studies on the AdVance ® sling published from 2008 to 2010 involving a minimum of 35 patients. Evidence synthesis The use of the AdVance ® sling in postprostatectomy incontinence results in success rates of 54.6–90.6% up to 1 yr. Lower success rates are linked to poor patient selection, early part of the learning curve for the technique, and debatable definitions of success. The technique is durable, and success rates of 67.7–77% have been reported at 2 yr. One-hour and 24-h pad weight tests also reflect the efficacy of the technique, with significant reductions reported. The AdVance ® sling is associated with significant improvements in patients’ quality of life and satisfaction. Common adverse events include mild dysuria, perineal and scrotal pain, and urinary retention, all of which resolved completely in a short period of time. Conclusions The AdVance ® transobturator nonobstructive sling is an effective and safe treatment of postprostatectomy incontinence. Durable results have been reported in large patient series.

Anatomical variation of bony pelvis from the viewpoint of transobturator sling placement for stress urinary incontinence

Introduction and hypothesisThe aim of the study was to investigate the variability of bony pelvis architecture from the viewpoint of transobturator sling placement.MethodsThe pelvimetry was performed on 122 women who underwent pelvic computed tomography. Measurements included: the distance between the interobturator foramina line and inferior pubic symphysis (IF-PS distance) as well as pubic arch angle, pubic ramus width, and pubic symphysis length.ResultsThe length of the IF-PS distance varied between 7.4 and 26.9 mm (mean 15.2 ± 4.3 mm, median 14.2 mm). The distribution of measurements was asymmetrical with a tilt of the values towards shorter distances. In 11.5% of women, the IF-PS distance was longer than 20 mm. The IF-PS distance correlated with the pubic ramus width (r = 0.37, p < 0.0001) and pubic arch angle (r = −0.22, p = 0.017).ConclusionThe IF-PS distance varies considerably in the general population of women.

Demographic and Clinical Predictors of Treatment Failure One Year After Midurethral Sling Surgery

To identify clinical and demographic factors predictive of midurethral sling failure. Overall treatment failure was defined by one or more of the following objective outcomes: a positive stress test, positive 24-hour pad test or retreatment for stress urinary incontinence (SUI); subjective outcomes: self reported SUI by the Medical, Epidemiologic and Social Aspect of Aging questionnaire, incontinent episodes by 3-day diary, or retreatment for SUI, or a combination of these. Logistic regression models adjusting for sling type and clinical site were used to predict odds of overall treatment failure after univariable analysis. Models were also fit to compare factors associated with objective failure and subjective failure only. Previous UI surgery (odds ratio [OR] 1.99, 95% confidence interval [CI] 1.14-3.47); maximum Q-tip excursion<30° (OR 1.89, 95% CI 1.16-3.05); Medical, Epidemiologic and Social Aspect of Aging questionnaire urge score per 10 points (OR 1.97, 95% CI 1.21-3.21); and pad weight per 10 g (OR 1.06, 95% CI 1.02-1.10) were predictors of overall failure. Having concomitant surgery (OR 0.44, 95% CI 0.22-0.90) was predictive of subjective failure only rather than objective failure. Age per 10 years (OR 1.48, 95% CI 1.14-1.90); Urogenital Distress Inventory score per 10 points (OR 1.09, 95% CI 1.02-1.17); pad weight per 10 g (OR 1.05, 95% CI 1.01-1.10) were predictive of objective failure compared with subjective failure only. Associations of risk factors and failure were similar independent of sling type (retropubic or transobturator). Twelve months after surgery, risk factors for overall and objective treatment failure were similar in women undergoing retropubic and transobturator sling procedures. This information may assist in counseling patients regarding efficacy of sling procedures and in setting expectations for women at increased odds for treatment failure. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00325039. II.

Risk factors of treatment failure after retrourethral transobturator male sling

Prospective evaluation of independent risk factors for failure of the retrourethral transobturator sling suspension (RTS) with special attention on sphincter function and surgical technique. A total of 189 patients with postprostatectomy stress urinary incontinence (SUI) were treated with RTS (AdVance(®) sling) in a prospective clinical study with a mean follow-up of 20.8 months. Eleven patients were lost to follow-up. Uni- and multivariate analyses were performed to identify independent risk factors for RTS failure. The success rate was defined as cured (no pad use or one dry 'security' pad) or improved (one to two pads and pad reduction ≥ 50%). At a mean follow-up of 20.8 months, the overall success rate was 73.1%. Multivariate analysis revealed that weak residual function and incomplete closure of the sphincter (OR, 29.0), no elongation of the coaptive sphincter zone (OR, 26.9), no sling tunnelling (OR, 22.6) and use of resorbable sutures with a small number (≤ 4) of stitches (OR, 8.4) are significant predictors for RTS failure. Preoperative selection of the patients with regard to residual sphincter function and a special attention on better sling fixation may increase RTS efficacy.