Treatment Of Urodynamic Stress Incontinence Research Articles

Comparison of adjustable and nonadjustable single-incision mini-slings in the treatment of female stress urinary incontinence: An initial experience with 30 cases

ObjectiveSeveral single-incision mini-slings (SIMSs) have been developed to minimize the potential complications associated with retropubic or transobturator mid-urethral slings. However, few studies compared the efficacy of different types of SIMS. This study compared the outcomes of an adjustable SIMS (Ajust) with a nonadjustable SIMS (Solyx) in the treatment of urodynamic stress incontinence (USI) over postoperative follow-up of 12 months. Materials and methodsIn this study, the surgical outcomes of the first 30 patients receiving Ajust and the first 30 patients undergoing Solyx at a university hospital were reviewed retrospectively, all of whom were diagnosed with USI without coexistent pelvic organ prolapse. Preoperative and postoperative examinations included structured urogynecological questionnaires, 1-hour pad tests, and complete urodynamic testing. Patient demographics, urodynamic parameters, and 12-months surgical outcomes were compared between the Ajust and Solyx groups. ResultsThere were no significant differences between the Ajust and Solyx groups in terms of subjective cure rate (93.3% vs 90.0%), objective cure rate (89.3% vs 89.3%), and de novo urgency or urge urinary incontinence (13.3% vs 16.7%) 12 months after surgery. Postoperatively, both Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7 scores were significantly improved in the Ajust and Solyx groups. In comparison with preoperative data, postoperative urodynamic results revealed a significant decrease in maximal urethral closure pressure in the Ajust group (n = 28) and a significant increase in residual urine in the Solyx group (n = 28). However, significant differences were not observed in the postoperative pad test and urodynamic data between the Ajust and Solyx groups, and no major complications occurred in either group. ConclusionsIn this paper describing the preliminary experience of 30 patients, both adjustable and nonadjustable SIMS performed by an experienced surgeon were safe and effective in correcting USI at 12-month postoperative follow-up.

Mid Urethral Slings for the Treatment of Urodynamic Stress Incontinence in Overweight and Obese Women: Surgical Outcomes and Preoperative Predictors of Failure

We evaluated mid urethral sling outcomes in overweight and obese patients compared to normal weight patients and identified risk factors for failure in this population. Records of 688 women between January 2004 and July 2017 were retrospectively reviewed. Patients received urodynamic studies, 1-hour pad test, Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7, and were divided into normal weight, overweight and obese. Objective cure at 1 year was defined as no involuntary urine leakage during filling cystometry and pad test less than 2 gm. Subjective cure was established by negative response to question 3 on Urogenital Distress Inventory-6. McNemar's test, chi-square test, Mann-Whitney U and Fisher's exact test were used for paired categorical variables. Independent samples t-tests and paired t-test were used for continuous parametric variables. Multivariate logistic regression was used to identify risk factors for failure. Objective and subjective cure in normal, overweight and obese patients was 91.4% and 89.1%, 87.5% and 86%, and 76% and 70.1%, respectively. There was no difference in surgical complications. Obese patients had worse quality of life scores preoperatively and postoperatively. Risk factors in obese patients with failed mid urethral sling included 66 years old or older (OR 2.02, 1.56-3.98), menopause (OR 4.21, 1.21-14.22), previous prolapse surgery (OR 4.57, 2.36-8.52), diabetes (OR 2.79, 1.61-5.99) and intrinsic sphincter deficiency (OR 5.06, 3.08-9.64). Obese women with mid urethral sling had lower objective and subjective cure at 1 year and worse quality of life scores compared to normal and overweight women. Risk factors for failure include age, diabetes, menopause, previous prolapse surgery and intrinsic sphincter deficiency.

Evaluation of Clinical Outcome and Risk Factors for Failure of Single-incision Midurethral Short Tape Procedure (Solyx Tape) for Stress Urinary Incontinence

To evaluate the clinical outcome and identify risk factors for failure of the Solyx (Boston Scientific Corporation, Marlborough, MA) single-incision sling (SIS) in the treatment of urodynamic stress incontinence (USI). A retrospective observational study (Canadian Task Force classification II-2). A tertiary referral center. Patients diagnosed with USI without needing concurrent procedures that underwent continence surgery using the Solyx SIS from February 2015 to May 2017. Anti-incontinence surgery. The primary outcome of this study was the rate of objective cure defined as the absence of demonstrable leakage of urine on the cough stress test and a 1-hour pad test weight of less than 2g. The secondary outcome was the rate of subjective cure defined as a negative response to Urinary Distress Inventory question 3 (no leakage on coughing, sneezing, or laughing) and the identification of the different risk factors of cure failure. A total of 113 patients were evaluated in the study. Postoperative USI and the 1-hour pad test significantly improved from 24.2 ± 26.9 gm (range, 19.1-29.3) to 2.5 ± 8.7 gm (range, 0.9-4.2); p <0.001 through 1 year. Data analysis showed an objective cure rate of 90% (102/113) and a subjective cure rate of 86% (97/113). USI recurred in 11 patients with no repeat surgery done becausesymptoms were tolerable to the patients. No patient had bladder outlet obstruction. Peak flow rates 23.7 ± 9.1 ml/s (20.0-27.4) and residual urine volume 38.5 ± 25.8 ml (29.8-47.2) were within normal limits with no significant changes. Previous anti-incontinent surgery, previous prolapsed surgery, intrinsic sphincter deficiency, maximum urethral closure pressure <40cm H2O, and neurogenic disease were significant risk factors for sling failure. Subjective assessment on the quality of life significantly improved (p <0.001). The Solyx SIS is an effective and safe treatment option for women with USI, showing high objective and subjective cure rates with a low incidence of complications 1 year after treatment. The identified independent risk factors forfailure are related to poor urethral function and previous pelvic reconstructive surgery.

Five-Year Outcome of MiniArc Single-Incision Sling Used in the Treatment of Primary Urodynamic Stress Incontinence

Study ObjectiveTo evaluate the effectiveness and safety of the MiniArc single-incision sling in the treatment of urodynamic stress incontinence (USI) through 5 years. DesignRetrospective observational study (Canadian Task Force classification II-2). SettingTertiary referral center. PatientsEighty-five patients with USI without needing concurrent procedures who underwent anti-incontinence surgery using the MiniArc SIMS from February 2010 to December 2011. InterventionsAnti-incontinence surgery. Measurements and Main ResultsObjective cure was defined as no demonstrable leakage of urine on the cough stress test and 1-hour pad test weight <2 g. Subjective cure was based on negative response to Urinary Distress Inventory question 3, no leakage on coughing, sneezing, or laughing. Most patients were postmenopausal, overweight, and multiparous. Postoperative USI significantly improved (p < .001) through 3 years, and the 1-hour pad test showed significant improvement through 5 years (p < .001). Although 13 patients had recurrence of USI, no repeat surgery was done. The cumulative cure rates may show a declining trend of cure, yet subjective cure was 80.0% and objective cure 84.7%, with age as a significant risk factor for sling failure. ConclusionMiniArc maintains its effectiveness and safety in treatment of USI through 5 years with high objective and subjective cure rates and low incidence of complications.

Uroflowmetric changes, success rate and complications following Tension-free Vaginal Tape Obturator (TVT-O) operation in obese females

ObjectiveThe goal of this study was to evaluate the outcome of Tension-free Vaginal Tape Obturator (TVT-O) operation in the treatment of urodynamic stress incontinence (USI) in obese females, with respect to uroflowmetric changes, success rate and postoperative complications. MethodsThis prospective observational study included 26 patients with USI at the Obstetrics & Gynecology department-Cairo University hospital during the year 2015. The participants had body mass index (BMI)≥30. Patients underwent TVT-O operation. Follow up of the patients was performed by cough test and uroflowmetry after one week, one month, three months and six months. Postoperative complications such as groin pain, sense of incomplete emptying, need to strain to complete micturition and urinary tract infection were recorded. Comparisons between groups were done using Chi square, Phi-Cramer test for categorical variables. ResultsThe mean age for the subjects was 43.58±9.01years. The mean BMI was 33.4±2.1. The success rate of TVT-O operation was 21 out of 26 patients (≈81%). Normal maximum flow rate was in 88% of patients at week one and was normal in 100% of patients at months three and six (p=0.101 & 0.101). Postoperative groin pain was the main complaint during the first week after operation and decreased significantly from week one to the 1st month postoperative (84.62% & 65.38%, P=0.041). ConclusionTVT-O operation showed a high success rate in treatment of USI in obese patients without affecting the voiding function of the bladder as proven by the uroflowmetry. The main postoperative complaint was the groin pain which significantly improved after one month.

Trans-Obturator Tape Operation Using MONARC Technique (Outside-In Technique) --- Revisited Objective And Subjective Assessment

Objective: This study was undertaken to describe and evaluate the outcome of trans-obturator tape (TOT) operation using Outside-In technique without cystoscopy. This procedure was carried out either solely or as a part of pelvic reconstructive surgery. Design: Retrospective cohort study with follow up objective and subjective assessment. Population: 84 women were presented with urodynamic stress incontinence at North Cumbria NHS Trust. They were treated with transoturator tape operation using outside-in technique between the years 2007 and 2008. Method: Eighty-four women underwent trans-obturator tape operation (outside-in technique) without cystoscopy. Diagnosis of stress urinary incontinence (SUI) was made by uro-dynamic studies. They were all operated only by a single surgeon. The mean length of follow-up was 6 months. Operative complications were recorded. The anatomic integrity of urethra, the anterior vaginal wall was objectively assessed at follow up visit. Subjective assessment was made during patient consultation. Objective failure was defined as persistence of urodynamic stress urinary incontinence. Subjectively, failure was defined mainly as persistence of stress incontinence symptoms. Other related symptoms are noted like voiding difficulties and sexual dysfunction. Results: In the study data eighty four women underwent a TOT operation. The mean age was 50 years (38-63). Pre-operatively, of those 84 patients, SUI was diagnosed in 62 patients while mixed urinary symptoms were present in 22 patients. Transobturator tape operation was carried out using MONARC subfacial hammock system in all women. Additional pelvic surgical procedures were performed according to the presence of other pelvic defects. No intraoperative complications were recorded. The estimated blood loss was 125 mL (range, 50-200 mL). None of the patient had suspected bladder or urethral injury intraoperatively. Transient urinary retention was observed in 8% (n= 7) of women in immediate postoperative period. Three women developed urinary tract infection in immediate postoperative period and in one woman urethral pus was noted which resolved with the help of oral antibiotics. Postoperative objective assessment was made with speculum examination and stress provocation tests like cough and valsalva manoeuvres. There was no stress incontinence on stress provocation tests. Two women developed de novo urge incontinence that was treated with anticholinergics. Two complained of worsening urge incontinence symptoms and none of the women having concurrent urge incontinence symptoms showed any improvement in their urge incontinence symptoms. The overall subjective success rate was 92% (n= 77). Six women judged themselves to be improved in terms of stress incontinence but were still wearing protection, although less, to avoid any urinary leakage. One woman gave history of prickling sensation in the vagina after the procedure at her follow-up visits, from 6 weeks to 9 months although she was reassured and that prickling sensation resolved at 9 month follow-up. Conclusion: Transobturator tape operation (outside-in technique) without cystoscopy seems an effective and safe treatment of urodynamic stress incontinence. It has a good subjective and objective outcome. A large study may be required to confirm the results.

Five-year follow-up study of Monarc transobturator tape for surgical treatment of primary stress urinary incontinence

We hypothesized that transobturator tape (TOT) is safe and efficacious for the treatment of urodynamic stress incontinence in the long term. We conducted a prospective study of patients with confirmed urodynamic stress incontinence (USI) who underwent a MonarcTM TOT procedure in a tertiary center between February 2006 and March 2009 without other concurrent surgical procedures. Urodynamics were conducted at 1 and 3years postoperatively. Subjective evaluation included Incontinence Impact Questionnaire (IIQ-7), Urinary Distress Inventory Questionnaire (UDI-6), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Objective cure was defined as no urinary leakage demonstrable on provocative filling cystometry and/ or 1-h pad test of <2g. Subjective cure was based on a negative response to question 3 in UDI-6. Paired-samples t test, chi-square, and Fisher exact tests were applied; p < 0.05 was considered significant. The log-rank tests were used to compare event-free survival. Sixty patients were enrolled, and 56 were evaluated at 5years postoperatively. The majority were middle aged, postmenopausal, and overweight. Mean operating time was 31.1 ± 8.9min, intraoperative complications were minor, and median period of follow-up was 80.3 ± 9.6months. At 5years of follow-up, objective and subjective cure rates were 89.3% and 87.5%, respectively. No mesh-related complications were seen. One patient needed a repeat midurethral sling procedure, and one patient each had bladder and bowel cancer. Monarc TOT was safe and retained its high cure rate in the short- and long-term treatment of stress urinary incontinence.

Is single incision midurethral sling effective in patients with low maximal urethral closure pressure?

ObjectiveTo ascertain whether low preoperational maximal urethral closure pressure (MUCP) affects the outcomes of single incision sling (SIS) procedures and changes MUCP values postsurgery. Material and methodsThere were 112 (MUCP ≥ 40 cmH2O, n = 88; MUCP < 40 cmH2O, n = 24) consecutive women with urodynamic stress incontinence who had undergone SIS (MiniArc) procedures included in this study. The threshold of 40 cmH2O was used since it has been shown to be a significant risk factor for failed incontinence surgery. Clinical outcomes were assessed by the cough stress test, the 1-hour pad test, the Incontinence Impact Questionnaire-Short Form, the Urogenital Distress Inventory six-item questionnaire, the Sexual Questionnaire-SF, and postoperative changes in the urodynamic parameters. A comparison of the 1-year follow-up data is presented. ResultsThree months postsurgery, a significant decrease was observed in the 1-hour pad test, from 20.6 g preoperatively to 0.73 g postoperatively (p < 0.001). The objective cure rate was 82.1% without any significant differences between the two groups (p = 0.202). At 3 months and 1 year after surgery, significantly decreasing Urogenital Distress Inventory six-item questionnaire and Incontinence Impact Questionnaire-Short Form, and increasing Sexual Questionnaire-SF scores were observed in both groups, without any significant differences between the two groups. No statistically significant difference in the subjective cured rate was noted between the two groups at the 3-month and 18.4 month follow-ups. The postoperative MUCP was significantly decreased in the MUCP ≥ 40 group (p < 0.05) while significantly increased in the MUCP < 40 group (p = 0.006). ConclusionsThese results suggest that SIS is a safe and highly effective treatment for urodynamic stress incontinence even in women with low MUCP at a mean follow-up of 18.4 months. Evaluation of the outcomes with more subjects after a longer follow-up period is necessary.

TVT for the treatment of urodynamic stress incontinence: Efficacy and adverse effects at 13-year follow-up.

To assess long-term subjective, objective, and urodynamic outcomes of retropubic mid-urethral slings at 13-year follow-up. This was a prospective observational study. Consecutive women with proven urodynamic stress incontinence were treated with standard retropubic tension free vaginal tape (TVT). Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded. All the included patients underwent preoperative clinical and urodynamic evaluations. During follow-up examinations, women were assessed for subjective satisfaction and objective cure rates. The Cox model was used in order to investigate factors predicting the risk of recurrent stress urinary incontinence (SUI), over the study period. Overall, 55 patients were suitable for the analysis. At 13-year follow-up, 47 out of 55 (85.5%) patients declared themselves cured (p-for-trend 0.02) and 48 out of 58 (87.2%) were at least improved (p-for-trend 0.07). No significant deterioration of objective cure rates was observed over time (P = 0.29). At the time of the last evaluation, 50 out of 55 (90.9%) women were objectively cured; urodynamic evaluation confirmed this finding in 49 (89.1%) patients. Considering factors predictive of SUI recurrence, we observed that, via multivariate analysis, obesity (HR 7.2; P = 0.01) and maximum detrusor pressure during the voiding phase ≤29 cmH2 O (HR 8.0; P = 0.01) were the only independent predictors of recurrent SUI. Our data confirmed that TVT is a highly effective and safe procedure also at 13-year follow-up. Interestingly, we observed a significant decrease of subjective satisfaction over time. Neurourol. Urodynam. 36:192-197, 2017. © 2015 Wiley Periodicals, Inc.

Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures

To explore, using 4D ultrasound, the importance of location and tension of transobturator sub- urethral tape (TOT) with respect to surgical outcome. Enrolled into the study were 56 women who had undergone TOT placement in the treatment of urodynamic stress incontinence. Tape location and tension were assessed by 4D ultrasound with the women at rest, during straining and during coughing. Ultrasound parameters representing tape location included the sagittal tape-symphysis pubis distance (sTSD), sagittal tape-symphysis pubis angle (sTSA) and tape percentile (an indication of tape position along the urethra with respect to urethral length), while those representing tape tension included urethral encroachment, sagittal tape-urethra distances at the upper end (sTUDu), center (sTUDc) and lower end (sTUDl) of the tape and axial urethral central echolucent area at the tape center (aUCEAc). In women in whom the tape procedure had been successful, during increased intra-abdominal pressure sTSA and the incidence of urethral encroachment increased, while sTUDu, sTUDc, sTUDl and aUCEAc decreased. Compared with those reporting no stress urinary incontinence (SUI) symptoms, women who reported SUI postoperatively had lower tape percentile. Women with SUI postoperatively demonstrated no manifestation on ultrasound of urethral encroachment at rest or during increased intra-abdominal pressure. Women with postoperative overactive bladder (OAB) symptoms had shorter resting sTSD and larger resting sTSA than did women without OAB symptoms. Women reporting postoperative de novo or worsening voiding difficulty had larger resting sTSA and higher incidence of urethral encroachment at rest than did women without this difficulty. Both tape location and tape tension are associated with surgical outcome of TOT procedures. Assessment of tape location and tension can be achieved using 4D ultrasound.

Tension-free Vaginal Tape for the Treatment of Urodynamic Stress Incontinence: Efficacy and Adverse Effects at 10-Year Follow-Up

BackgroundOne of the most effective and popular current procedures for the surgical treatment of stress urinary incontinence (SUI) is tension-free midurethral slings. ObjectiveTo evaluate the outcomes of women with retropubic tension-free vaginal tape (TVT) for urodynamic stress incontinence (USI) after 10-yr follow-up. Design, setting, and participantsThis was a prospective observational study. Consecutive women with proven USI were treated with TVT. Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded. InterventionStandard retropubic TVT. MeasurementsPatients underwent preoperative clinical and urodynamic evaluations. During follow-up examinations, women were assessed for subjective satisfaction and objective cure rates. Multivariable analyses were performed to investigate outcomes. Results and limitationsA total of 63 women were included. After 10 yr, 5 patients (8%) were lost or no longer evaluable. The 10-yr subjective, objective, and urodynamic cure rates were 89.7%, 93.1%, and 91.4%, respectively. These rates were stable across the whole study period (p>0.99). De novo overactive bladder was reported by 30.1% and 18.9% of patients at 3-mo and 10-yr follow-up, respectively (p for trend = 0.19). A total of 84.2% of women with detrusor overactivity received antimuscarinic drugs, but 43.8% were nonresponders 12 wk later. At multivariable analysis, maximum detrusor pressure during the filling phase >9cm H2O (hazard ratio [HR]: 16.2; p=0.01) and maximum detrusor pressure during the voiding phase ≤29cm H2O (HR: 8.0; p=0.01) were independent predictors for the recurrence of SUI, as well as obesity was for the recurrence of objective SUI (HR: 17.1; p=0.01) and of USI (HR: 8.9; p=0.02), respectively. Intraoperatively, bladder perforation occurred in two cases; no severe bleeding or other complications occurred. ConclusionsThe 10-yr results of this study seem to demonstrate that TVT is a highly effective option for the treatment of female SUI, recording a very high cure rate with low complications after a 10-yr follow-up.

The Impact of Mid‐Urethral Slings for the Treatment of Urodynamic Stress Incontinence on Female Sexual Function: A Multicenter Prospective Study

Urinary incontinence is a common condition that negatively impacts on female sexuality (FS). To evaluate FS before and after a mid-urethral sling (MUS) procedure using the Female Sexual Function Index (FSFI). We included women that were both sexually and nonsexually active at baseline. One hundred fifty-seven women complaining of urodynamic stress incontinence underwent a MUS procedure and were enrolled in the study. All patients answered the Italian translation of FSFI, before and 12 months after surgery. To understand the real impact of the MUS on female sexual function, for the first time in the literature, we also monitored and included in the final analysis all the women who are nonsexually active at baseline. We evaluated the prevalence of female sexual dysfunction according to the FSFI cutoff point (26.55). FSFI total score, pads use, and stress test presurgery and postsurgery. One hundred thirty-three patients completed the study protocol: 105 out of 133 underwent to a trans-obturator procedure, while 28 out of 133 had a retropubic procedure. After the 12-month follow up, 115 out of 133 patients (86%) were dry, 10 improved their symptoms, and the remaining 8 were unchanged. Seventy-nine out of 133 (59%) patients reported an active sexual life before surgery. Fifty-four (41%) reported they were not sexually active before surgery. Twelve months after surgery, 22 out of 54 nonsexually active women (40%) reestablished sexual activity, whereas only 6 out of 79 (7.5%) patients, sexually active at baseline, were not sexually active 1 year after surgery (P < 0.05). After adjusting for multiple testing, only age, menopause, and storage symptoms remained significantly correlated with the FSFI total score postsurgery as independent variables. Conclusions. Our data showed that after a MUS procedure, female sexual function improves. We also found that a very relevant percentage of nonsexually active women reported renewed sexual activity after MUS.

What patients think: patient-reported outcomes of retropubic versus trans-obturator mid-urethral slings for urodynamic stress incontinence—a multi-centre randomised controlled trial

The purpose of this study is to determine if the trans-obturator tape (TOT; Monarc, American Medical Systems (AMS)), which has been claimed to have similar or improved outcomes to retropubic mid-urethral slings, was equivalent (but not inferior) to the trans-vaginal tape (TVT; Gynecare) by using patient-reported outcomes for the treatment of urodynamic stress incontinence. The primary outcome was the percentage cured of the symptom of stress urinary incontinence at 12 months on the International Consultation on Incontinence Modular Questionnaire-Female Lower Urinary Tract Symptoms question, 'does urine leak when you are physically active, exert yourself, cough or sneeze?'. Secondary outcomes included: quality of life, pain scores, global impression of improvement, patient satisfaction and complications. Objective assessments included cough stress test, urinary diary and pad test. At 12 months, 55 (65.5%) of the TVT group and 59 (63.4%) of the TOT group reported no stress incontinence. TOT was not inferior to TVT. There was less blood loss and pain with TOT than with TVT. There were improvements in quality of life, sexual function and patient satisfaction within groups but not between groups. Patient-reported outcomes have shown that TOT is not inferior to TVT, but both produce lower success rates than studies using objective measures.

A Prospective Study of Surgeon and Patient-Perceived Outcome following Transobturator Tape Insertion for Treatment of Urodynamic Stress Incontinence

Introduction: Transobturator tape (TOT) placement for stress incontinence (USI) is recommended following failure of conservative therapy. The literature shows that in the short-term efficacy is comparable to tension-free vaginal tape (TVT) and open colposuspension (OC). The study aim was to report a large consecutive cohort undergoing TOT insertion by a single surgeon specifically for both surgeon- and patient-perceived outcome. Patients and methods: Over 4 years at our institution 98 women underwent TOT insertion by a single surgeon. All women had preoperative urodynamics, 79% had type I and 21% type IIa USI. Perioperative and outpatient follow-up data were prospectively collected. Patient-perceived outcome was assessed using a mailed validated questionnaire. Results: Results are similar to other published series. Median operative time was 19 min (15–30) and blood loss 21 mls (15–60). Self-catheterisation was necessary for 13 patients. Vaginal perforation occurred in two patients. At follow-up (mean 7.1 months) 86/93 (92%) patients were dry and 23 (26%) women reported urinary symptoms. 80 (81%) women responded to the questionnaire (mean 18 months) and 54 (68%) describing complete cure. Conclusions: This large single-surgeon series confirms the safety and efficacy of TOT and illustrates the difference between surgeon and patient-perceived outcome. Results obtained are comparable to previously published series for TOT, TVT and OC.

Lynx® midurethral sling system: a 1-year prospective study on efficacy and safety

The objective of this study is to determine the outcomes for the Lynx midurethral sling system in the treatment of urodynamic stress incontinence (USI). Prospective study of 118 subjects who underwent a Lynx midurethral sling procedure for USI. Subjects were considered cured if they were subjectively dry by history and objectively dry by standing stress test. Intraoperative and postoperative complications were documented. Complete information was available on 102 (86%) subjects at 1 year. Ninety-two patients were considered cured, and ten were failures. There were four intraoperative bladder perforations and five (4.2%) erosions. Two patients developed urinary retention with one resolving at 31 days and the other undergoing subsequent takedown at 6 months. Both remain dry at 12 months. The Lynx midurethral sling system shows high subjective and objective success rates for the treatment of USI at 1 year with low rates of intraoperative and postoperative complications.

Peri-operative morbidity and early results of a randomised trial comparing TVT and TVT-O: response to comment by Minassian and colleagues

We really appreciate the comments of Dr. Minassian and co-workers on our study regarding the comparison between tension-free vaginal tape (TVT) and tension-free vaginal tape obturator (TVT-O) in the treatment of urodynamic stress incontinence [1] and we hope to answer all the questions and remarks they raised. We did not describe both surgical techniques in the article as they were reproduced exactly as the promoting authors, Prof. Ulmsten [2] and Prof. deLeval [3], suggested, except for using different types of anaesthesia in patients undergoing TVT. Therefore, we believed that a full description of the techniques was unnecessary for most of the readers. The procedure time was different, and we agree that 9 min difference has poor clinical and economic relevance, but this was not one of our outcome measures and probably is related to the fact that cystoscopy was performed only in half of the patients undergoing TVT-O. Unfortunately, the original study protocol shared by all participants included cystoscopy for both procedures; but collecting data for the analysis, we realized that some centres did not perform it in all the patients. Most of the patients, 75 (65%) in TVT group and 70 (60%) in TVT-O group, underwent surgery under locoregional anaesthesia; therefore, patients who received general anaesthesia are a small part of the entire sample: six (5%) and 23 (19%). This difference could be explained by the fact that an intraoperative cough test was performed in 62% of the cases in TVT group compared with 15% in TVT-O group. We remind you that the original procedure included the cough test for TVT but not necessarily for TVT-O. Nevertheless, despite this different behaviour, the success rate was similar between the procedures. Time for surgery was calculated at the beginning of the procedure once the patient was ready to be operated on and timerequiredfor anaesthesia was not taken intoconsideration. On the other hand, we agree that time to perform cystoscopy could be responsible for longer time in TVT group. In the original description of the TVT-O procedure, cystoscopy was not considered mandatory but, nevertheless, we included it in our study protocol. As we said before, despite this, the adherence to the study protocol was not complete, and some surgeons did not perform it as suggested. We believe that there were no bladder or urethral perforations as no patient came back either reporting irritative bladder symptoms or micturition disorders; moreover, at physical examination, no fistula or erosion was observed.

Transobturator Suburethral Tapes in the Management of Urinary Incontinence: Success, Safety and Impact on Sexual Life

The tension-free vaginal tape (TVT) procedure has, in the past decade, become the most popular treatment for urodynamic stress incontinence (USI). A variant of the TVT operation is the transobturator tension-free vaginal tape (TOT) procedure, of which there are 2 forms: Obtape (the outside-in technique) and TVT-0 (the inside-out technique). This retrospective study compared the efficacy and safety of the 2 TOT procedures and their effects, if any, on patients' sexual lives. Participants were 94 women with USI or mixed incontinence who had the TVT-0 operation at a tertiary referral center in Scotland in the years 2002-2005 and 182 others having the Obtape procedure. The mean age was 49 years, and mean parity was 2. The 2 groups did not differ significantly with regard to body mass index, urodynamic diagnosis, or previous incontinence surgery. Evaluative instruments included the urinary domain of the Birmingham Bowel and Urinary Symptoms Questionnaire, the International Consultation on Incontinence Questionnaire Short Form, the Sexual Impact Questionnaire, and a visual analogue scale to estimate patient satisfaction. After a median follow-up interval of 28 months, the success rates-as estimated subjectively and based on no or only occasional episodes of incontinence-were 86% in patients with USI and 52% in those with mixed incontinence (P < 0.001). Urgency became worse postoperatively in 8% of patients. Rates of bladder and urethral injury were less than 1%, and there were no significant differences in intraoperative or early postoperative complications between the 2 surgical groups. Late postoperative complications were significantly more frequent in the Obtape group and included de novo urgency and vaginal erosions. No substantial change was found in the frequency of intercourse and pleasure or pain during penetration. Coital incontinence declined significantly after surgery. Only 13% of women described sexual intercourse as being worse or much worse after surgery. About 8% of patients experienced vaginal dryness that caused discomfort. The TOT operation is an effective and relatively safe treatment for USI. The vast majority of women in this study reported improvement or no change in their sexual lives. Overall complication rates were similarly frequent with the inside-out and outside-in procedures, but there were significantly more tape-related complications after use of the Obtape (outside-in) technique.

Modified conservative management of polypropylene tape vaginal erosion

Tension-free vaginal tape procedures have been used for many years for the treatment of urodynamic stress incontinence in women. Synthetic mesh slings carry a risk of erosion into the vagina or ure...

Simple sling resection and a second, intermediate polypropylene mesh for treatment of vaginal tape protrusion concurrent with recurrent urinary stress incontinence after TVT procedure

The tension-free vaginal tape (TVT) procedure is a simple, effective and minimally invasive method for the surgical treatment of urodynamic stress incontinence (USI). Yet, complications such as mesh protrusion and recurrent urinary leakages after TVT have been reported. A case of recurrent USI complicated with vaginal mesh protrusion following a TVT procedure was referred. Video-urodynamics and introital ultrasonography confirmed that the recurrence of USI was secondary to mal-position of the protruded TVT. A simple salvaging procedure was carried out. The mal-positioned distal protruded TVT was resected and a second intermediate piece of polypropylene (Prolene) mesh was replaced at mid-urethra. The operation time was short and blood loss was minimal. The patient was objectively continent at 6 months follow-up with no defect of healing. Considering the cost-effectiveness and invasiveness of the surgeries, the method of inserting an intermediate mesh is clinically useful.

A multi-centre, randomised clinical control trial comparing the retropubic (RP) approach versus the transobturator approach (TO) for tension-free, suburethral sling treatment of urodynamic stress incontinence: the TORP study

To compare the safety and efficacy of the transobturator tape (Monarc) with the retropubic tape (tension-free vaginal tape, TVTR) for the treatment of urodynamic stress incontinence (USI) a prospective, single-blinded, multi-centre randomised clinical controlled trial was undertaken in four urogynaecology units in Australia. One hundred and eighty-seven women with USI were randomly allocated to undergo surgery with either the Monarc sling (n = 80) or TVT (n = 107). Outcome measures were intra-operative complications (especially bladder injury), as well as peri-operative complications, symptomatology, quality of life and urodynamic outcomes. At 3 months, data were available on 140 women, 82 (59%) TVT and 58 (42%) Monarc. The TVT group was significantly more likely to be complicated by bladder injury (7 TVT, 0 Monarc, p < 0.05). Blood loss and operative time were significantly less in the Monarc group, which was 49 mls (31) vs that of the TVT group, which was 64 mls (41) p < 0.05; 18.5 min (6.5) TVT vs 14.6 min (6) Monarc (p < 0.001). The subjective and objective stress incontinence cure rates were 86.6% (71) vs 72.4% (42) p = 0.77 and 79.3 vs 84.5%, p = 0.51 for the TVT and Monarc groups, respectively. Both groups reported similar improvement in incontinence impact and satisfaction with their operation, although return to activity was significantly quicker with the transobturator route (p = 0.029). The transobturator tape appears to be as effective as the retro-pubic tape in the short term, with a reduction in the risk of intra-operative bladder injury, shorter operating time, decreased blood loss, and quicker return to usual activities.