Urethral Sling Procedures Research Articles

TOT versus TVT – mesh surgical treatment in stress urinary incontinence

Introduction: Stress urinary incontinence is a highly debilitating condition, with an important impact over the quality of life. When the conservative treatment fails, the surgical treatment is a viable solution. Minimally invasive sling procedures have become the gold standard of surgical management for stress urinary incontinence (SUI) in women. Material and methods: The study was conducted on 68 patients with stress urinary incontinence, 52 have undergone the retropubic tension-free vaginal tape and 16 patients were operated using the transobturator tape procedure. All the patients were evaluated before the operation and the indication of the surgical treatment was established on the basis of physical examination (all the patients had positive cough test), abdominal ultrasound (to determine postvoid residual urine volume), urinalysis and urine culture (the majority of the patients have had before the operation recurrent urinary tract infections). Results: The satisfaction was similar in both groups of patients, with an average satisfaction rate of 91% for TVT and 86% for the patients who have undergone TOT procedure. The patients were in a proportion of 78,9% at menopause, with an average number of natural births of 1.9 and a mean BMI of 28.2. Regarding the surgical duration, this has varied between 20 and 40 minutes, being higher in the TVT cases (up to 5-7 minutes longer than TOT), because cystoscopy was performed during the operation to verify if the bladder was perforated or not. The urethral catheter was removed immediately after the operation in the case of the TOT procedure and in the day after the operation for the patients who have undergone TVT procedures (all of these patients associated genital prolapse). The hospitalization time was 3 days. We haven’t encountered significant intraoperative and postoperative complications. Conclusions: The TOT and TVT procedures have proven to be highly effective and safe methods in the treatment of SUI. There are no significant differences regarding the efficacy of these two surgical methods, but the risk of intraoperative complications is a little higher for the TVT procedure. The mid urethral sling procedures improve significantly the quality of life for patients with stress urinary incontinence.

Complications érosives des bandelettes sous-urétrales (BSU) : 10 ans d’expérience chirurgicale

Evaluation of the diagnostic and therapeutic management of erosive complications after mid urethral sling (MUS) procedure: vaginal erosions (VE), bladder (BE) and urethral (UE). Retrospective monocentric study concerning cohort of patients undergoing surgery from January 2002 to January 2013 supported for erosive complications of MSU: TVT (Tension-free Vaginal Tape) or TOT (Trans-Obturateur Tape). Sixteen patients were diagnosed for erosive complications: 7 VE, 6 BE and 3 UE. Dyspareunia and vaginal discharge were observed in 86% patients (n=6/7) with VE. Conservative treatment by vaginal approach was systematically performed in cases of vaginal erosion. After removal of material, 100% dyspareunia were corrected. Postoperative continence was maintained in 57% of patients (n=4/7). Urinary infection was the main symptom of patients with BE. Severe dysuria was present in 66% of patients with a UE (n=2/3). First-line therapy by endoscopic treatment was performed in 77% of patients (n=7/9) with a BE or UE. A second surgery was required in 42% of patients treated with endoscopic first-line therapy (n=3/7) because of a new exposure of MUS. Three of nine patients recurred their incontinence after first-line therapy (33%). The removal of device exposed vaginally in case VE systematically corrected symptoms with about 60% of continence. In case of BE or UE, endoscopic treatment in first-line therapy was rarely definitive (42%) and recurrence of incontinence appeared in 30% cases.

Surgery for urinary incontinence in women 65 years and older: a systematic review.

Urinary incontinence (UI) is common among the elderly, but the literature is sparse on the surgical treatment of UI among the elderly. This systematic review aims to assess the effectiveness of surgical interventions as treatment for urinary incontinence in the elderly population ≥65 years of age. Randomized controlled trials (RCT) and prospective nonrandomized studies (NRS) were included. The databases PubMed (NLM), EMBASE (Elsevier), Cochrane Library (Wiley), and Cinahl (EBSCO) were searched for the period 1966 up to October 2013. The population had to be ≥65 years of age and had to have undergone urethral sling procedures, periurethral injection of bulking agents, artificial urinary sphincter surgery, bladder injection treatment with onabotulinumtoxin A or sacral neuromodulation treatment. Eligible outcomes were episodes of incontinence/urine leakage, adverse events, and quality of life. The studies included had to be at a moderate or low risk of bias. Mean difference (MD) or standard mean difference (SMD)as well as risk difference (RD) and the 95% CI were calculated. Five studies--all on the suburethral sling procedure in women-- that fulfilled the inclusion criteria were identified. The proportion of patients reporting persistent SUI after surgery ranged from 5.2 to 17.6%. One study evaluating quality of life (QoL) showed a significant improvement after surgery. The complication rates varied between 1 and 26%, mainly bladder perforation, bladder emptying disturbances, and de novo urge. The suburethral sling procedure improves continence as well as QoL among elderly women with SUI; however, evidence is limited.

Practice patterns of post-radical prostatectomy incontinence surgery in Ontario.

We assess the practice patterns of artificial urinary sphincter (AUS) and urethral sling insertion after radical prostatectomy (RP) from a large population-based cohort. We examined 25 346 men in Ontario, Canada who underwent RP between 1993 and 2006. Using hospital and cancer registry data, we identified patients who subsequently underwent an incontinence procedure. We characterized the practice patterns of post-prostatectomy incontinence procedures across Ontario during the study interval. A total of 703 (2.8%) men underwent subsequent insertion of an AUS and 282 (1.1%) underwent a urethral sling procedure (985 total incontinence procedures, 3.9%) over the study period. During the study period, 121 hospitals performed RP. Among them, 32 (26%) hospitals performed both RP and AUS/sling procedures, and 89 (74%) performed RP only. Four hospitals performed AUS/sling procedures but not RP. Of the 36 institutions that performed AUS/sling procedures, the median annual case volume was 0.29 (interquartile range: 0.083-0.75). Of all incontinence procedures, 56% were performed at 3 academic institutions. When examining observed rates of AUS/sling procedures compared with expected rates from the overall cohort, 15 of 32 hospitals (47%) performed significantly fewer incontinence procedures than expected given their RP case volume (p range: <0.0001-0.0390) and 5 (16%) performed significantly more (p range: <0.0001-0.038). A small number of academic institutions provide most of the surgical care for men with incontinence following RP in Ontario. Many centres that perform RP refer out to other centres to surgically manage their patients' incontinence.

Surgical treatment of neurogenic stress urinary incontinence: A systematic review of quality assessment and surgical outcomes.

There are many opinions but little firm knowledge about the optimal treatment of neurogenic stress urinary incontinence (NSUI). To scrutinize the quality and surgical outcomes of the available treatment modalities in the published literature. A systematic review of the published literature from Pub Med and Web of Science was undertaken for studies describing surgical treatment of NSUI between 1990 and 2013. A checklist of criteria of methodological and reporting quality of interventions in urological publications was applied to assess quality of the retrieved publications. Surgical outcomes of success, failure, and reoperation were calculated. Statistical analyses included one-way ANOVA and post-hoc tests to determine significant differences between groups. Thirty studies were identified with Level 3 evidence. The quality of reporting was 43-81%, with significantly higher quality noted in studies published after 2002 (64% vs. 45%, P < 0.0001). None of the studies followed a randomized controlled trial (RCT) design. Three primary surgical procedures were used in 29 of 30 studies: artificial urinary sphincter (AUS), urethral slings, and urethral bulking agents. One study used a ProACT device. AUS was considered more successful than urethral bulking agents (77 ± 15% vs. 27 ± 20%, P = 0.002). Urethral bulking agents reported higher failures than urethral sling procedures (49 ± 16% vs. 21 ± 19%, P = 0.016) and AUS (21 ± 19% vs. 10 ± 11%, P < 0.002). The quality of evidence obtained from non-RCTs is modest. Surgeries for NSUI have relatively high success rates but also high complication rates in this highly heterogeneous population. More studies using modern techniques are required to update our knowledge.

A Meta-Analysis of the Performance of Retropubic Mid Urethral Slings versus Transobturator Mid Urethral Slings

We evaluate the efficacy and complications after retropubic and transobturator mid urethral slings in the treatment of female stress urinary incontinence. A systematic literature review was performed using MEDLINE®, limited to randomized controlled trials with a minimum followup of 1 year and type 1 grafts. Statistical analyses were performed using StatsDirect Version 2.7.9 (StatsDirect Ltd, Altrincham, UK). Retropubic mid urethral sling procedures showed statistically significant improvements in objective cure (OR 1.35, 95% CI 1.10-1.67, p=0.005) and subjective cure (OR 1.24, 95% CI 1.04-1.49, p=0.02). Bladder perforations (OR 5.72, CI 2.94-11.12, p <0.0001) and bleeding (OR 2.65, CI 1.54-4.59, p=0.0005) were significantly more common with retropubic mid urethral slings, whereas vaginal perforations (OR 0.29, CI 0.15-0.56, p=0.0002) and neurological symptoms (OR 0.35, CI 0.25-0.5, p <0.0001) were more common with transobturator mid urethral slings. Operative time was significantly longer for retropubic mid urethral slings than transobturator mid urethral slings (OR 1.38, p <0.0001). No significant differences were noted in mesh erosions and exposure, urinary retention, infection, lower urinary tract symptoms and length of hospital stay. Retropubic mid urethral slings showed better objective and subjective cure rates than transobturator mid urethral slings. However, bladder perforation and bleeding were more common with retropubic mid urethral slings. Operative time was longer for retropubic mid urethral slings. Transobturator mid urethral slings were associated with more cases of neurological symptoms and vaginal perforation.

The Bladder Neck Sling: What Role Remains?

A decade ago, bladder neck slings were recognized as the gold standard technique for a majority of patients. Today, tension-free vaginal tape is widely accepted as the standard approach for index surgery in female stress urinary incontinence. Recently published articles have demonstrated a decrease in the use of bladder neck slings and a significant increase in the use of mid urethral synthetic slings. Currently, bladder neck sling procedures appear to confer a cure rate similar to open retropubic colposuspension and mid urethral sling procedures, but the long-term adverse event profiles are still unclear. Although, bladder neck slings remain in the armamentarium of pelvic surgeons, they are reserved mainly for pediatric patients and for complex patients at high risk for urethral damage, with recurrent urinary incontinence and with low-pressure urethras, as well as for the patients who may refuse having synthetic slings. This article reviews the role of bladder neck slings in the era of the midurethral slings.

How do urogynaecologists treat failed suburethral slings? Experience from the British Society of Urogynaecology database and literature review

Midurethral urethral sling (MUS) procedures have high success and satisfaction rates. A small percentage of MUS operations will fail and most centres have limited experience of treating this outcome. The aim of this study was to review the British Society of Urogynaecology (BSUG) database for women who underwent repeat anti-incontinence surgery after failed MUS. A total of 313 repeat surgical procedures were identified. For any failed MUS, the commonest second surgical intervention was a repeat retropubic MUS and was used in 54% (170/313) of repeat procedures. Bladder neck injections were the second commonest repeat procedure (43/313 cases: 14%). TVT-Os were used as repeat surgery in 12% (38/313) and TOTs in 8% (25/313). Small numbers of colposuspensions (20/313, 6%) and Aldridge slings (6/313, 2%) were also used. A variety of different surgical treatments are used for failed MUSs. From the BSUG database review, the commonest second surgical intervention was a repeat retropubic MUS.

A Randomized, Controlled Trial Comparing an Innovative Single Incision Sling With an Established Transobturator Sling to Treat Female Stress Urinary Incontinence

Mid urethral sling procedures have become the surgical treatment of choice for female stress urinary incontinence. Innovative modifications of mid urethral sling procedures were recently introduced with the claim of offering similar efficacy and decreased morbidity. We compared the efficacy and morbidity of an innovative single incision mid urethral tape and an established transobturator procedure. We performed a prospective, randomized, controlled trial in 6 teaching hospitals in Belgium and The Netherlands between 2007 and 2009. A total of 96 patients received a TVT Secur™ single incision sling and 98 received a TVT™ Obturator System. We collected data on patient characteristics, surgery related parameters, adverse events, clinical followup, Urogenital Distress Inventory and SF-36® scores, validated questionnaires on daily life activities and visual analog scores objectifying pain. Followup was 1 year. One-year followup was available for 75 single incision sling and 85 obturator system cases. Stress urinary incontinence could be objectified in 16.4% of the patients with a single incision sling and in 2.4% with an obturator system (p <0.05). Stress urinary incontinence was subjectively reported by 24% of single incision sling and 8% of obturator system patients (p <0.05). One year after surgery the mean ± SD UDI incontinence domain score in the single incision sling and obturator system groups was 21 ± 24 and 13 ± 21, respectively (p <0.01). Patients with a single incision sling experienced significantly less pain during the first 2 weeks after surgery (p <0.05) and returned significantly earlier to normal daily activity. The OR of re-intervention for stress urinary incontinence 1 year after receiving a single incision sling vs an obturator system was 2.3 (95% CI 1.9-2.7). The single incision sling procedure is associated with less postoperative pain and a lower objective cure rate than the obturator system procedure.

Force of Stream After Sling Therapy: Safety and Efficacy of Rapid Discharge Care Pathway Based on Subjective Patient Report

We evaluated the safety of a mid urethral sling postoperative care pathway using patient subjective reporting of force of stream to minimize length of stay and catheter placement. Women undergoing solitary mid urethral sling surgery were prospectively enrolled in our study. Force of stream after the sling therapy protocol consisted of retrograde bladder filling with 300 ml fluid within 1 hour after surgery. Patients rated force of stream compared to baseline on a visual analog scale. Those with a force of stream of 50% or greater were immediately discharged home regardless of post-void residual urine volume. Only those unable to void and those rating force of stream less than 50% with post-void residual urine volume greater than 500 ml were discharged home with a catheter. Patients were telephoned within 1 week of surgery and seen 4 to 6 weeks postoperatively. The primary outcome was unexpected visits to the emergency room or office for voiding dysfunction or urinary retention. A total of 114 women were prospectively enrolled in our study, of whom 105 (92.1%) passed the protocol and were discharged home without a catheter. Of the patients 14 were discharged home with increased post-void residual urine volume (range 152 to 427 ml) but no catheter, representing those who would have been discharged with a catheter by many traditional voiding protocols. According to protocol 9 patients were discharged with a catheter. No patient presented to the emergency room or office in urinary retention or with voiding dysfunction before the scheduled visit. Patients who report a force of stream of 50% or greater can be safely and rapidly discharged home after an uncomplicated mid urethral sling procedure regardless of post-void residual urine volume. Scanned post-void residual urine volume does not add much value in those who can void. By following the force of stream after sling therapy protocol patients can be discharged home less than 3 hours after mid urethral sling surgery.

Stress Urinary Incontinence: A Review of Treatment Options

Stress urinary incontinence occurs when the support structures of the pelvic floor and the urinary system are stretched, damaged, or defective. This condition is common in women of all ages, and billions of dollars are spent each year to correct the condition and improve quality of life. This article reviews three current treatments for stress urinary incontinence: the Burch colposuspension procedure, urethral slings, and radiofrequency treatments. In one study, researchers reported that patient satisfaction rates were higher for the Burch procedure than for urethral sling procedures. Other researchers found that urethral sling procedures had high rates of success but that adverse events were more common. Adverse events for both types of procedures include voiding difficulties, postoperative urge incontinence, and urinary tract infections. Radiofrequency interventions can improve the quality of life for many patients and can provide a short-term intervention for many patients who later may require a more-invasive surgical procedure.

Repeat synthetic mid urethral sling procedure for women with recurrent stress urinary incontinence

Repeat synthetic mid urethral sling procedure for women with recurrent stress urinary incontinence

Risk Factors for Trocar Injury to the Bladder During Mid Urethral Sling Procedures

Risk Factors for Trocar Injury to the Bladder During Mid Urethral Sling Procedures

Repeat Synthetic Mid Urethral Sling Procedure for Women With Recurrent Stress Urinary Incontinence

We reported and compared the outcomes of repeat mid urethral sling with primary mid urethral sling in women with stress urinary incontinence. A total of 1,225 consecutive women with urodynamic stress incontinence underwent a synthetic mid urethral sling procedure (955 retropubic, 270 transobturator) at our institution between 1999 and 2007. Of the patients 91% (1,112) were interviewed via telephone call with a structured questionnaire and were included in the analysis. Mean +/- SD followup was 50 +/- 24 months (range 12 to 114). A comparison between repeat (77, mean age 62 +/- 12 years) and primary (1,035, mean age 60 +/- 13 years) mid urethral sling groups was performed. Repeat sling was placed without removal of the previous sling. The preoperative incidence of intrinsic sphincter deficiency was higher in patients who had a repeat mid urethral sling (31% vs 13%, p <0.001). The subjective stress incontinence cure rate was 86% and 62% in the primary and repeat group, respectively (p <0.001). The repeat retropubic approach was significantly more successful than the repeat transobturator approach (71% vs 48%, p = 0.04). The rates of sling related and general postoperative complications were similar between the primary and the repeat groups. However, de novo urgency (30% vs 14%, p <0.001) and de novo urge urinary incontinence (22% vs 5%, p <0.001) were more frequent in the repeat group compared with the primary group. A repeat synthetic mid urethral sling procedure has a significantly lower cure rate than a primary mid urethral sling procedure. The repeat retropubic approach has a higher success rate than the repeat transobturator approach. The incidence of de novo urgency and urge incontinence are significantly higher in repeat procedures.

Risk Factors for Trocar Injury to the Bladder During Mid Urethral Sling Procedures

We determined the incidence of and risk factors for bladder injury during mid urethral sling procedures for stress urinary incontinence. At our institution 1,136 consecutive women underwent a mid urethral sling procedure (retropubic in 874 and transobturator in 262) and routine intraoperative cystoscopy between 1999 and 2007, and were followed to determine the clinical outcome. Statistical analysis was performed using the chi-square and independent t tests, and ANOVA to compare patients with and without bladder perforation by baseline characteristics and major risk factors. A total of 45 variables were included in analysis. Multivariate analysis to predict events was done with logistic regression models with stepwise forward selection. Bladder injury was noted in 34 patients (3%) and all except 1 were during a retropubic sling procedure (p <0.0001). Of the perforations 32 (94%) were associated with an inexperienced surgeon (p <0.0001). Multivariate analysis revealed that rectocele (OR 6.2), local anesthesia (OR 5.9), body mass index less than 30 kg/m(2) (OR 5.6), previous Cesarean section (OR 3.7) and previous colposuspension (OR 3.2) were significant independent risk factors for perforation. Urethral injury was detected intraoperatively in 2 women (0.2%) with a retropubic sling. Our results indicate that previous Cesarean section, colposuspension, body mass index less than 30 kg/m(2), rectocele and local anesthesia are independent risk factors for bladder perforation during mid urethral sling procedures. This occurs mainly during a retropubic sling procedure and when the surgeon is inexperienced.

Predictors of Success With Postoperative Voiding Trials After a Mid Urethral Sling Procedure

We identified predictors of passing a voiding trial after incontinence surgery with a mid urethral sling and examined if successful performance on a voiding trial was maintained. A total of 89 women scheduled for incontinence surgery were enrolled from July 2005 until April 2006. Voiding trials were performed the day of discharge from the hospital, with a two-thirds volume void after a 300 ml fill considered passing. Those who passed underwent a second voiding trial 3 hours later. Of the participants 60 (67.4%) underwent tension-free vaginal tape surgery, 29 underwent transobturator tape (32.6%) and 64 (71.9%) underwent concurrent vaginal repairs. A total of 59 (67.0%) participants passed the first voiding trial. Univariate analysis identified 12 potential predicting variables for passing the first voiding trial. From these 12, model building via backward stepwise logistic regression found maximum flow on preoperative uroflowmetry to be the only significant predictive variable (p = 0.0002). Of the 59 women who passed the initial voiding trial 9 (16.4%) failed the second voiding trial. None of the 11 participants who had maximal flow rates greater than 30 cc per second failed the first or second voiding trial, whereas 17 of 22 subjects (77.3%) who had maximal flow rates less than 15 cc per second failed either of these trials. Maximum flow rates on preoperative uroflowmetry were the best predictor of passing an initial voiding trial after undergoing a mid urethral sling procedure for incontinence. However, the ability to maintain performance on a second voiding trial, even only 3 hours after passing an initial trial, is not assured.

Outcomes Following Repeat Mid Urethral Synthetic Sling After Failure of the Initial Sling Procedure: Rediscovery of the Tension-Free Vaginal Tape Procedure

We evaluated outcomes of the repeat mid urethral sling to treat recurrent or persistent stress urinary incontinence after failure of an initial mid urethral sling. We retrospectively analyzed data on patients who underwent the repeat mid urethral sling procedure due to persistent or recurrent stress urinary incontinence. Repeat slings were placed without removal of the previous sling. All patients were followed at least 1 year after the second mid urethral sling. Of the 31 female patients with a repeat mid urethral sling 29 were followed, including 13 with a retropubic and 16 with a transobturator sling. For the first mid urethral sling 17 patients received a retropubic sling (tension-free vaginal tape) and 12 received a transobturator sling (6 inside out and 6 outside in procedures). Cure and improvement rates irrespective of the approach were 75.9% (22 of 29 patients) and 6.9% (2 of 29), respectively. Cure rates for the retropubic and transobturator slings were 92.3% (12 of 13 patients) and 62.5% (10 of 16), respectively, a difference that did not quite attain statistical significance (p = 0.089). The repeat mid urethral sling for persistent or recurrent stress urinary incontinence has a lower cure rate than the initial sling. However, the retropubic approach tends to have a higher cure rate than the transobturator approach in repeat sling cases.

Factors Influencing the Outcome of Mid Urethral Sling Procedures for Female Urinary Incontinence

We evaluated the outcome at least 6 months after the tension-free vaginal tape or transobturator tape procedure in women with urinary incontinence, and identified factors predicting persistent stress urinary incontinence. A total of 464 women 28 to 80 years old (mean age 56) were included in the study. Tension-free vaginal tape (252) and transobturator tape (212) procedures were performed by the same surgeon. Mean followup was 10.8 months (range 6 to 52). Bladder perforations were noted in 12 patients (4.8%) in the tension-free vaginal tape group but there was no bladder perforation after the transobturator tape procedure (p = 0.001). The rate of urinary retention in the tension-free vaginal tape group was significantly higher than that in the transobturator tape group (15.1% vs 6.6%, p = 0.004). The overall cure rate was significantly higher in the tension-free vaginal tape group than in the transobturator tape group (92.1% vs 84.9%, p = 0.015). On multivariate analysis 4 variables were independent risk factors for persistent stress urinary incontinence, that is comorbid disease (OR 2.37, 95% CI 1.26-4.47, p = 0.008), urge urinary incontinence (OR 1.95, 95% CI 1.02-3.74, p = 0.044), severe grade of cystocele (OR 2.73, 95% CI 1.43-5.20, p = 0.002) and transobturator tape procedure (OR 2.87, 95% CI 1.50-5.47, p = 0.001). The cure rates in women with urinary incontinence are not similar after tension-free vaginal tape and transobturator tape procedures. Our findings suggest that characteristics including the type of procedure, comorbid diseases, mixed urinary incontinence and severe grade cystocele should be considered high risk factors for persistent stress urinary incontinence in these patients.

Long-term outcomes of the distal urethral polypropylene sling procedure for stress urinary incontinence

Long-term outcomes of the distal urethral polypropylene sling procedure for stress urinary incontinence

Rektumperforation als Spätkomplikation einer ProACT-Implantation

Operative approaches to solve severe urinary incontinence following radical prostatectomy include artificial urinary sphincters, bulking agents, urethral sling procedures, and the ProACT device (Uromedica Inc.). Previously reported complications of the ProACT procedure comprise ruptures and dislocations of balloons as well as erosions and perforations of the bladder or urethra. We report the case of a rectal perforation as a late complication of the ProACT procedure after prostatectomy and adjuvant radiotherapy. To the best of our knowledge this complication has not been described before.