两种入路尿道中段悬吊术治疗女性压力性尿失禁的临床效果比较

目的 比较经耻骨后和闭孔入路经阴道尿道中段无张力悬吊术治疗女性压力性尿失禁的临床效果和并发症.方法 应用经阴道尿道中段无张力悬吊术治疗女性压力性尿失禁患者134例,根据手术入路的不同分为两组:耻骨后组(32例)和闭孔组(102例).对两组的手术时间、失血量、治愈率和有效率以及术后并发症进行比较.结果 耻骨后组和闭孔组的手术时间分别为(24±6)min和(22±5)min,术中失血量分别为(45±27)ml和(54±23)ml,治愈率分别为81.25%和78.43%,有效率分别为96.88%和98.04%,两组比较差异无统计学意义(P＞0.05).两组术后并发症的发生率分别为:新发尿急6.25%和5.88%,排尿困难:3.13%和2.94%,膀胱损伤:3.13%和0%,阴道损伤:0%和2.94%,两组比较差异无统计学意义(P＞0.05).术后腹股沟疼痛的发生率分别为3.13%和20.59%,两者差异有统计学意义(P＜0.05).结论 耻骨后入路和闭孔入路尿道中段悬吊术均是治疗女性SUI的有效术式.     

A prospective trial comparing tension-free vaginal tape and transobturator vaginal tape inside-out for the surgical treatment of female stress urinary incontinence: 1-year followup

PURPOSE: We prospectively compared the efficacy and safety of tension-free vaginal tape and transobturator vaginal tape inside-out for female stress urinary incontinence. MATERIALS AND METHODS: A total of 120 women with stress urinary incontinence were alternately assigned to the tension-free vaginal tape group (60) or the transobturator vaginal tape inside-out group (60). Preoperative evaluation included urodynamic study and a Korean version of the incontinence quality of life questionnaire. One year after operation the surgical result, patient satisfaction, incontinence quality of life questionnaire, long-term complications and uroflowmetry were evaluated in the 2 groups. RESULTS: Patient characteristics were comparable in the 2 groups. Mean +/- SD operative time was significantly shorter in the transobturator vaginal tape inside-out vs the tension-free vaginal tape group (11 +/- 1.4 vs 15 +/- 1.8 minutes). In the transobturator vaginal tape inside-out and the tension-free vaginal tape groups the rates of cure (86.8% and 86.8%), improvement (6.6% and 8.2%) and failure (6.6% and 5.0%, respectively) were similar. Incontinence quality of life questionnaire parameters 1 year after surgery were improved significantly in each group and there was no difference between the 2 groups (p <0.001 and >0.05, respectively). There was no long-term complication in either group. Preoperative urge incontinence resolved in 80% of the tension-free vaginal tape group and in 100% of the transobturator vaginal tape inside-out group. De novo urgency developed in 4 patients (6.6%) in the transobturator vaginal tape inside-out group. CONCLUSIONS: The tension-free vaginal tape and transobturator vaginal tape inside-out procedures were minimally invasive and similar in operation related morbidity. Transobturator vaginal tape inside-out appeared to be as effective and safe as tension-free vaginal tape for the surgical treatment of stress urinary incontinence in women at 1-year followup.     

Diagnosis, management and prognosis of vaginal erosion after transobturator suburethral tape procedure using a nonwoven thermally bonded polypropylene mesh

PURPOSE: We studied the diagnosis, management and prognosis of vaginal mesh erosion using a thermally bonded nonwoven polypropylene mesh in a transobturator suburethral tape procedure for the surgical treatment of stress urinary incontinence in women. MATERIALS AND METHODS: A total of 65 patients diagnosed with stress urinary incontinence underwent a transobturator suburethral tape procedure with a fusion welded, nonwoven, nonknitted polypropylene mesh, with or without a central silicone coated section, at our institution. All women were followed and if vaginal erosion was diagnosed, cystoscopy and vaginoscopy were performed, the mesh was partially or completely removed and, if necessary, posterior cough test and urodynamic study were performed. RESULTS: Of the 65 patients 9 (13.8%) were diagnosed with vaginal erosion at the vaginal incision during a relatively long postoperative period (mean 290 days). All presented with vaginal discharge and 1 had a severe complication (obturator abscess). Complete mesh removal was necessary in 8 patients and only 2 (22%) had recurrent stress urinary incontinence. CONCLUSIONS: A 13.8% rate of vaginal mesh erosion using a nonwoven thermally bonded polypropylene mesh was reported. This complication was probably due to the characteristics of the mesh and not to the transobturator approach. Complete removal of the tape is recommended and the continence status prognosis is good (78%).     

Transvaginal vs transobturator approach for synthetic sling placement in patients with stress urinary incontinence

We present comparative short-term experience with the transvaginal (TVT) and the transobturator (TVT-O) approaches for the treatment of stress urinary incontinence (SUI). We studied 315 women with SUI, treated with a tension-free tape placement. The TVT approach was applied in 265 women, while 50 women were treated by the TVT-O approach. The mean operation time was 25 and 17 min in the TVT and TVT-O group, respectively (p < 0.001). In the TVT group, continence rates were 87% after 1 year, while in the TVT-O group, the continence rate was 94%. Postoperative pain was reported in 14.4 and 28% of the TVT and TVT-O patients, respectively (p = 0.02). Complications such as bladder perforation, retropubic hematoma, and urinary retention took place only in the TVT group. Urinary tract infections were recorded in 20 and 8% of the TVT and TVT-O patients, respectively (p = 0.04), while vaginal erosion took place in 1.5 and 2% and de novo urgency in 14 and 8%. Both approaches show high rates of cure at the first postoperative year, while complications are less with the TVT-O procedure.     

A late complication of transobturator tape procedure: vaginocutaneous fistula formation with vaginal mesh erosion

Transobturator tape procedures are a common treatment modality in patients with stress urinary incontinence (SUI). Various complications have been reported related to this procedure. We present a rare case of vaginocutaneous fistula formation 5 years after transobturator tape surgery. A 56-year-old woman presented with complaints of increased vaginal discharge, difficulty in coitus, and serosanguineous discharge from the left groin 5 years after transobturator tape surgery for SUI. Pelvic examination revealed 2–3 cm of extruded mesh at the anterior vaginal wall. The vaginocutaneous fistula was detected at surgery. The suburethral tape was removed, and the fistula tract was excised and repaired primarily. Postoperative period was uneventful, and the patient was still continent 6 weeks postoperatively. With widespread use of mesh for treating SUI, we will likely see a variety of complications in the long term.     

A prospective study of transobturator tape as treatment for stress urinary incontinence after transvaginal mesh repair

Introduction and hypothesis

The transobturator suburethral sling is a common surgical treatment for stress urinary incontinence (SUI). In patients with incontinence after trocar-guided transvaginal mesh repair (Prolift?), data on outcome remain limited. In the present study, we hypothesized that transobturator tape in such cases is assumed to be as effective as surgery alone.

Methods

This was a prospective analysis of outcomes of transobturator slings in women who had undergone transvaginal mesh repair and in those who underwent sling surgery alone (controls). Objective cure was defined as the absence of urinary leakage during the stress test at filling cystometry and a negative cough test during pelvic examination. The success rates were evaluated 3–6 months postoperatively.

Results

One hundred women were recruited for the study. Compared to the control group, women after transvaginal mesh repair had a significantly lower objective success rate (62 vs 86 %, p?=?0.005) and poorer bladder neck mobility (0.5?±?0.8 vs 1.1?±?0.5 cm, p?=?0.001).

Conclusions

The transobturator sling has lower objective success rate in women after transvaginal mesh that may be due to decreased bladder neck mobility. Patients with post-mesh repair SUI who opt for sling surgery should be informed of these less satisfactory outcomes during preoperative counseling.     

四种中段尿道吊带术治疗女性压力性尿失禁的比较

目的比较4种中段尿道吊带术治疗女性压力性尿失禁（stress urinary incontinence,SUI）的疗效。方法回顾分析80例行中段尿道吊带术的女性SUI患者的临床资料,其中改良Stamey法14例、In-fast法12例、TVT法42例及TVT-O法12例。结果组间比较,手术时间有显著性差异（P〈0.05）,其中TVT-O组时间最短,为（18.8±4.3）min,改良Stamey组时间最长,达（52.1±5.4）min。80例患者随访3~100个月,70例（87.5%）治愈,尿失禁症状完全消失;7例（8.75%）改善;3例（3.75%）失败。改良Stamey组、In-fast组、TVT组及TVT-O组治愈率分别为78.6%、75.0%、92.9%及91.7%,无统计学差异（P〉0.05）。改良Stamey组2例患者术后出现排尿困难,经多次下压式尿道扩张无效而剪断悬吊线;In-fast吊带组1例患者因阴道吊带外露而拆除,TVT组及TVT-O组术后各有1例患者出现排尿困难,经下压式尿道扩张后解除梗阻。结论4种尿道吊带术疗效相似,均为治疗女性压力性尿失禁安全、有效的方法;其中TVT-O因操作简单手术时间最短。     

Present state of female urology

This chapter critically reviews the literature on surgery for stress urinary incontinence (SUI) and pelvic organ prolapse (POP), and medical treatment for overactive bladder in women. The midurethral polypropylene sling was reported to provide a durable option with significant improvement. The tension-free vaginal tape (TVT) procedure is based on a theory of pathophysiology of stress incontinence presented by Petros and Ulmsten. In their "integral theory" impairment of the pubourethral ligament is one of the primary cause of SUI. The transobturator sling was found to be effective in SUI patients with less incidence of perioperative complications and voiding difficulties. Prolapse of the uterus/vaginal apex and posterior vaginal wall may also be found in women with stress incontinence. There are many procedures for the correction of POP. Transvaginal repair of anterior and posterior compartment prolapse with polypropylene mesh has been developed in recent years. It is necessary to assess and compare the current quality of outcomes.     

Monarc transobturator sling system for the treatment of female urinary stress incontinence: results of a post-operative transvaginal ultrasonography

The aim of the study was to determine Monarc (American Medical Systems) sling position after surgical treatment of stress urinary incontinence (SUI) through the transobturator approach. A total of 54 consecutive women with SUI were evaluated post-operatively with transvaginal ultrasound. A concomitant hysterectomy was performed in ten cases and a concomitant prolapse surgery in six cases. Ultrasound measurements include urethral length, the distance between the upper edge of the sling and the bladder neck (BN–S) and the BN–S/U ratio. The mean distance between the transobturator tape and the bladder neck was found to be 12.6 ± 3.2 mm in the group of patients who underwent the transobturator procedure alone, 13 ± 3.1 mm in the transobturator plus hysterectomy group and 12 ± 2.8 mm in the transobturator plus prolapse group. The superior tape margin was at the mid-urethra in 81.5% of patients and always at a distance greater than 7 mm from the bladder neck. Eight patients did not have satisfactory results after the surgery. Only in one out of these eight patients was the transobturator sling not found to be at the mid-urethra. The superior tape margin of the Monarc sling remained at the level of mid-urethra in the majority of cases. It was never located too proximally beneath the bladder neck.     

Transobturator vaginal tape inside out procedure for stress urinary incontinence: results of 102 patients

Multiple behavioral and surgical treatments exist for the treatment of stress urinary incontinence (SUI). We report herein on the safety and efficacy of the transobturator vaginal tape inside out (TVT-O) procedure for patients with SUI. A retrospective study of 102 consecutive patients with SUI who underwent the TVT-O procedure was conducted. Pre and postoperative evaluations included urodynamic studies and a 60-min pad test. Based on the 4th and 8th week postoperative evaluations, 97 of 102 (95%) patients had a complete cure. Of 88 patients who were followed for 12 months, 84 (95%) achieved a complete cure. Two instances of intraoperative lateral vaginal sulcus perforation occurred. Pain over the inner thigh was noted in 17 (17%) patients. Mesh erosion was noted in one case. TVT-O procedure is a safe, effective, and minimally invasive procedure for SUI with a low rate of complications.     

经闭孔无张力尿道中段吊带术联合阴道前壁修补术治疗女性压力性尿失禁

目的 评价经闭孔无张力尿道中段吊带术(TVT-O)联合阴道前壁修补术治疗合并阴道前壁脱垂的女性压力性尿失禁(stress urinary incontinence,SUI)的效果.方法 行TVT-O联合阴道前壁修补术治疗合并阴道前壁脱垂的女性压力性尿失禁18例.术后随访12个月,进行主观治疗结果及术后远期并发症的调查.术后12个月时,复查盆腔器官脱垂定量分度法(POP-Q)分期、尿流率、性生活质量评分(PISQ-12).结果 尿失禁主观治愈率为88.9%(16/18),主观改善率为11.1%(2/18).4例阴道前壁脱垂复发(术前Ⅲ期3例,Ⅱ期1例,术后均为Ⅰ期),11名有规律性生活的患者PISQ-12评分术前术后分别为27.5±4.4和31.2±6.1(P＜0.05).结论 TVT-O联合阴道前壁修补术治疗合并中度阴道前壁脱垂的女性压力性尿失禁简便易行,疗效可靠,对患者性功能无不利影响.     

经耻骨后和经闭孔尿道中段无张力悬吊术治疗女性压力性尿失禁的疗效观察

目的:观察经耻骨后和经闭孔尿道无张力悬吊术治疗女性压力性尿失禁(Stress urinary incontinence,SUI)的疗效。方法:选择女性SUI患者198例,病程2~25年,平均7.3年;年龄41~78岁,平均58.3岁。采用经耻骨后无张力阴道吊带术(tension-free vaginal tape,TVT,57例为TVT组)或经闭孔尿道下无张力吊带术(transobturator vaginal tape inside-out,TVT-O,141例为TVT-O组)进行治疗。结果:本文患者随访6~120个月,179例(90.4%)治愈,其中TVT组平均随访86个月,治愈51例(89.5%),改善4例(7%);TVT-O组平均随访38个月,治愈128例(90.7%),改善6例(4.3%);疗效不佳9例(3.5%)。TVT组2例发生膀胱穿孔(3.5%),TVT-O组3例出现腹股沟血肿伴下肢大腿根部疼痛,2例出现短期单下肢活动障碍,但经保守治疗均好转;术后拔除尿管后排尿困难5例,其中TVT组2例,TVT-O组3例,经多次下压式尿道扩张及延长保留尿管后解除梗阻、恢复正常排尿4例;TVT组中1例采用尿道扩张无效而剪断悬吊带。结论:经阴道中段无张力悬吊术(尤其是TVT-O)操作简便,疗效佳,并发症少,是治疗女性SUI的有效方法。     

The use of polypropylene mesh as a transobturator sling for the treatment of female stress urinary incontinence (early experience with 40 cases)

This study evaluated the use of traditional polypropylene mesh, used in hernias repair, as a sling in the treatment of female stress urinary incontinence (SUI). Forty patients diagnosed with SUI underwent transobturator sling fashioned from the ordinary polypropylene mesh (vypro II®). Each lateral end of the tape is secured by a zero prolene suture. The procedure was then done outside-in, and the patients were followed up. The mean operative time was 40–60 min when the procedure was performed alone or accompanied with associated pelvic floor repair. Thirty-five patients (87.5%) were cured, and two patients (5%) significantly improved, but the procedure failed in three patients (7.5%), and the slings were removed because of vaginal erosion. Polypropylene mesh transobturator sling is an easy and cheap method for the treatment of female SUI with a high success rate.     

由内向外经闭孔尿道中段悬吊术治疗女性压力性尿失禁的并发症

目的：探讨由内向外经闭孔尿道中段悬吊术（TVTO）治疗女性压力性尿失禁（SUI）的并发症及其处理办法。方法：对经TVT-O治疗的100例SUI患者的临床资料进行分析,了解术中、术后出现的并发症及处理措施。结果：SUI治愈80例,治愈率80％,改善18例（18％）。发生阴道损伤3例,新发尿急6例．排尿困难3例。术后腹股沟区发生疼痛21例,出现网带腐蚀2例,经相关处理后均缓解。2例手术失败,术后拔出尿管尿失禁改善,但分别在术后2周、4周时症状复发,改行其他方法治愈。结论：TVT-O治疗SUU疗效较好．但手术并发症时有发生并需及时作相应处理;术后腹股沟痛可能与神经损伤有关。     

Tension-free vaginal tape versus transobturator tape for treatment of female stress urinary incontinence

Objectives  

The transobturator tape (TOT) is based on a similar principle as the tension-free vaginal tape (TVT), but introduced through the obturator foramen. The aim of this study was to compare these slings as surgical procedures for the treatment of stress urinary incontinence (SUI) in women.     

Management of recurrent stress urinary incontinence and urinary retention following midurethral sling insertion in women

INTRODUCTION

Synthetic midurethral slings are the most common operations performed for women with stress urinary incontinence (SUI). However, there is only very scarce evidence regarding the management of complications from these operations. The aim of this survey was to canvass expert opinion regarding the management of recurrent SUI and urinary retention following insertion of these slings.

METHODS

Expert urologists and urogynaecologists in the UK with an interest in SUI were identified. Three clinical scenarios on recurrent SUI and one on urinary retention following midurethral sling placements were emailed twice to the experts.

RESULTS

The majority of the experts chose a repeat synthetic midurethral retropubic transvaginal tape (TVT) as the procedure of choice for recurrent SUI in patients who had had a previous TVT or midurethral transobturator tape inserted. In patients who continued to suffer SUI after a failed second TVT, there were mixed results with experts choosing fascial slings, colposuspension and bulking agents as their preferred method of treatment. In women who develop urinary retention following a TVT, tape pull-down within two weeks was the preferred method among the experts. However, division of the tape within two to six weeks following the procedure was also popular.

CONCLUSIONS

Based on expert opinion, it is difficult to make a recommendation as to the best method of treating recurrent SUI or urinary retention following tape insertion. There is an urgent requirement for well conducted, multicentre, randomised clinical trials to look at the management of these complications and also the tools used to assess the patient before salvage surgical management.     

Comparison between the retropubic and transobturator approaches in the treatment of female stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications

Objective

This study aimed to compare the effectiveness and complications between the retropubic and transobturator approaches for the treatment of female stress urinary incontinence (SUI) by conducting a systematic review.

Materials and Methods

We selected all randomized controlled trials (RCTs) that compared retropubic and transobturator sling placements for treatment of SUI. We estimated pooled odds ratios and 95% confidence intervals for intraoperative and postoperative outcomes and complications.

Results

Six hundred twelve studies that compared retropubic and transobturator approaches to midurethral sling placement were identified, of which 16 were included in our research. Our study was based on results from 2646 women. We performed a subgroup analysis to compare outcomes and complications between the two approaches. The evidence to support the superior approach that leads to better objective/subjective cure rate was insufficient. The transobturator approach was associated with lower risks of bladder perforation (odds ratio (OR) 0.17, 95% confidence interval (CI) 0.09-0.32), retropubic/vaginal hematoma (OR 0.32, 95% CI 0.16-0.63), and long-term voiding dysfunction (OR 0.32, 95% CI 0.17-0.61). However, the risk of thigh/groin pain seemed higher in the transobturator group (OR 2.53, 95% CI 1.72-3.72). We found no statistically significant differences in the risks of other complications between the two approaches.

Conclusions

This meta-analysis shows analogical objective and subjective cure rates between the retropubic and transobturator approaches to midurethral sling placement. The transobturator approach was associated with lower risks of several complications. However, good-quality studies with long-term follow-ups are warranted for further research.     

Results and complications of TVT procedure in the surgical treatment of female stress incontinence

ObjetivesTo evaluate the efficacy and safety of Tension-free vaginal tape (TVT) for treatment of female stress urinary incontinence (SUI).To determine the mid-term outcome of TVT performed during other pelvic floor reconstructive procedures.Patients and methods100 women with SUI undergoing TVT procedure under spinal anesthesia from January 2000 to 1November 2002 were studied.76 women were treated with TVT alone. 24 patients were treated with TVT and pelvic floor reconstruction: we repaired 24 cystoceles grade II-III, 3 rectoceles and 4 concomitant vaginal histerectomies.ResultsMean age was 49,3 years (range 35-78). Mean parity: 2 (range 0-6) and mean operative time was 38 minutes (range 20 to 50). The postoperative hospital stay was 24 hours for women treated with TVT alone. Only 1 patient (1%) need bladder catheterization during 7 days due to urinary retention.Mean followup was 18 months (range 12-48). Objetive cure rate was 95%. In our study the rate of de novo post-operative urge symptoms (16%) was the most frequent complication. Bladder injury was the most grave problem and it happened in 1 patient (1%).ConclusionThe results confirm the feasibility and safety of TVT for treatment of SUI. Moreover, TVT procedure is economical and efectiveness.Pelvic floor defects, benign uterine disorders and SUI can be safely treated with TVT and vaginal procedures during the same surgical time.     

Complications of tension-free vaginal tape surgery: a multi-institutional review

OBJECTIVE: To analyse the complications of tension-free vaginal tape (TVT) surgery, a minimally invasive alternative for treating patients with stress urinary incontinence (SUI), at six institutions, and to review the management of these complications and their effect on patient outcome. PATIENTS AND METHODS: In all, 241 patients who had a TVT procedure by six urologists at six hospitals (two university and four community) were reviewed retrospectively by the same urologist. Complications during and after surgery, and their management, were analysed. RESULTS: Complications during surgery included bladder perforation in 48 patients (5.8%) and blood loss > 500 mL in 16 (2.5%). Immediate complications after surgery were urinary retention (>24 h after) in 47 patients (19.7%), pelvic haematoma in four (1.9%) and suprapubic wound infection in one (0.4%). Of the 47 patients in retention, 32 were in retention for <48 h and treated with an indwelling catheter. The 15 remaining patients were treated with an indwelling catheter (one) or clean intermittent catheterization for a mean of 22 days. To correct the retention the TVT was released in seven patients and the tape sectioned in three. Late complications were de novo urgency, persistent suprapubic discomfort and intravaginal tape erosion in 36 (15%), 18 (7.5%) and one (0.4%) patient, respectively. Most of these complications resolved with observation and medical management, but intravaginal tape erosion required partial resection of the tape with closure and repair of the vaginal mucosa. CONCLUSIONS: The present TVT complication rates were slightly higher than reported previously. This multi-institutional review in both academic and community hospitals may better reflect the morbidity of TVT insertion in clinical practice. TVT is a highly effective, minimally invasive method for treating SUI. A stricter definition of each complication and a better understanding of the mechanism of these complications may further improve the surgical outcome and decrease patient morbidity.     

Vaginal wall erosion after transobturator tape procedure

Transobturator Prolene tape insertion represents a new method of operative treatment for stress urinary incontinence. The first results show that it is a simple and effective procedure accompanied by a minimum number of complications. Since February 2004, 30 Monarc procedures were done at our department and no intraoperative complications were observed. However, two cases (6.7%) of vaginal wall erosion due to the Prolene tape were noted 6 weeks after surgery. In a subsequent surgical procedure, the periurethral portion of the tape was removed and a new Prolene tape was placed through the retropubic space. Three months after secondary surgery both patients were continent, with no sign of erosion. The transobturator approach was introduced to minimize the risk of complications. However, the greater prevalence of vaginal wall erosion after this procedure found in our series demands a scrupulous search for this complication and for the mechanisms leading to its occurrence.