耻骨后膀胱颈悬吊术（Raz术）和TVT-0术治疗女性压力性尿失禁的对比

目的：观察耻骨后膀胱颈悬吊术（Raz术）和经闭孔经阴道无张力尿道中段悬吊术（TVT-O术）治疗重度女性压力性尿失禁的疗效。方法：对64例重度女性压力性尿失禁患者分为2组,分别用Raz术治疗患者31例,TVT-O术治疗患者33例,对术中情况分析及治疗后的效果进行定期随访。结果：Raz术治疗的有效率为87．09％,TVT-O术治疗的有效率为90．90％。差异无统计学意义（P〉0．05）。Rza术平均手术时间约80min,术中出血约150ml,术后并发症：尿潴留4例,术中损伤膀胱3例;TVT-O术平均手术时间约20min,术中出血约50ml,术后无膀胱损伤、尿潴留并发症。结论：Raz术和TVT-O术相比,疗效均显著,但后者比前者具有损伤小,操作简单,出血少,手术时间短,恢复快等优点。     

Exploratory study assessing efficacy and complications of TVT-O, TVT-Secur, and Mini-Arc: results at 12-month follow-up

Background

Contemporary surgical treatment of female stress urinary incontinence (SUI) includes retropubic and transobturator (TO) midurethral slings (MUS). Case series of single-incision slings (SIS) have shown similar outcomes with lower morbidity.

Objective

Our aim was to assess the cure rates, complications, and quality-of-life impact of one standard TO MUS and two SIS.

Design, setting, and participants

Ninety consecutive patients with clinically and urodynamically proven SUI were enrolled in an exploratory randomised phase 2 trial. Patients with previous SUI surgery, major pelvic organ prolapse, mixed incontinence, or detrusor overactivity were excluded.

Interventions

Patients were treated randomly with TVT-O, TVT-Secur, or Mini-Arc.

Measurements

Postoperative visits were scheduled at 6 and 12 mo. The King's Health Questionnaire (KHQ) was repeated at 6 mo. Cure was defined as the absence of urine leakage, no pad use, and a negative cough test at 12 mo. Pain and other complications were also investigated.

Results and limitations

Cure rate was 83% after TVT-O, 67% after TVT-Secur, and 87% after Mini-Arc. Improvement was found in 10%, 13%, and 7% of the patients, respectively. Failures were 7% after TVT-O and Mini-Arc and 20% after TVT-Secur.TVT-O and Mini-Arc improved at least 15 points in >80% of the patients in six KHQ domains, whereas TVT-Secur could only achieve improvement in three of the nine domains. The pain score was lower in the Mini-Arc group. Complications were more numerous after TVT-O. This study has the limitations inherent in a phase 2 trial with a follow-up limited to 12 mo.

Conclusions

Mini-Arc offers cure and improvement rates similar to TVT-O, whereas TVT-Secur may yield an inferior outcome. These findings recommend the urgent launch of large randomised phase 3 studies comparing conventional MUS with SIS, with Mini-Arc the advised option.     

三种网片悬吊术治疗女性压力性尿失禁的疗效比较

目的对童氏前路悬吊术、经闭孔无张力阴道中段悬吊术（TVT-O）与改良TVT—O术三种网片悬吊术治疗女性压力性尿失禁的疗效进行对比评估。方法对采用童氏前路悬吊术治疗的36例患者,改良TVT—O39例,TVT-030例患者在手术安全性、疗效及并发症等方面进行回顾性分析。结果三组术式在手术时间、术中出血、损伤、近期尿猪留、治愈率及满意度等方面无统计学差异。结论三种术式对尿失禁的治疗效果相似,但童氏前路悬吊术不经盆腔．完全在直视下进行,相比改良TVT—O和TVT—O术更为经济、安全,操作简单,也可在基层医院内进行推广。     

Trans-obturator urethral sling for the surgical correction of female stress urinary incontinence: Outside-in (Monarc) versus inside-out (TVT-O): Are the two ways reassuring?

INTRODUCTION: In 2001, the trans-obturator route was proposed for the surgical positioning of tape with a view to avoiding the retropubic space and its disadvantages. The route, originally described outside-in by Delorme was presented inside-out by de Leval. Since then, anatomical discussions have attempted to prove that one technique is safer than the other. OBJECTIVE: Demonstrating the safety of the two techniques through personal and published experience. MATERIAL AND METHODS: Non-randomized, prospective, observational, open-label, longitudinal study of 100 female patients (50 tension-free vaginal tape (TVT)-O and 50 Monarc). All the female patients presented with isolated stress urinary incontinence. Only four patients presented with mixed incontinence in the Monarc (MON) group. Sphincter incompetence was observed four times in the MON group and three times in the TVT-O group. Almost all the patients were undergoing their first procedure. All the patients underwent surgery under assisted local anesthesia in a day-hospital setting. All the patients underwent a full gynecological examination and a urodynamic assessment. Only those patients presenting with patent established urinary incontinence, corrected by the TVT test, underwent surgery. Post-operative control was conducted at 3 months and 1 year when a physical examination and urodynamic assessment were implemented. RESULTS: All the patients underwent control up to time point 12 months. The duration of hospitalization was 10h for 48 patients in the MON group and 49 in the TVT-O group. The duration of hospitalization was 24h for one patient in each group and 4 days for one patient in the TVT-O group due to transient urine retention. The only per-operative complication was a vaginal perforation in the lateral angle of the vagina for a MON patient. Tape repositioning was necessary. Early post-operative complications were observed in the MON group: three cases of urinary tract infection, one of transient urine retention, three of pain in the thighs spontaneously resolving within 4 days and one of permanent pain in one leg at time 1 year, which remained bearable. For the TVT-O group the post-operative complications consisted in: one case of urinary tract infection, one of transient retention and four of pain in the thigh. No hematoma was reported in either group. Amongst the late complications, the de novo symptoms included one case of imperious urges to urinate in the TVT-O group and objective dysuria in two cases in the MON group versus seven in the TVT-O group. There was no statistically significant between-group difference in the complications. No tape exposure was observed. Overall, the recovery rate was 90% at 1 year for MON versus 94% for TVT-O (p=NS) with two cases of recurrence between 3 months and 1 year in that series. Mixed incontinence was corrected at time point 1 year in 75% of cases for MON, with one case of recurrence in the year. For the patients presenting with sphincter incompetence, competence was maintained at 3 months and 1 year in all cases in the MON group. The three TVT-O were cured at 3 months, but two recurrences were observed at 1 year. Almost all the patients were satisfied or very satisfied at time point 1 year and those who had sexual relations (54%) did not report any disorder at time point 1 year. DISCUSSION: The outside-in technique necessitates more marked peri-urethral dissection and vesical complications are possible. The cadaveric studies by the outside-in partisans show a vascular and nervous risk, which has little reflection in terms of complications in the literature. Post-operative leg pains are encountered with both techniques and are usually only transient. All the studies of the two routes report a recovery rate of over 90% for pure stress incontinence. CONCLUSION: The author's experience, like that reported in the literature, shows that the two trans-obturator access routes are equally safe and do not require per-operative cystoscopic control. The clinical results would appear to be equivalent, in terms of recovery, to the rates obtained with retropubic TVT. Attempting to find anatomical or etiological arguments in order to prove one technique superior to the other appears somewhat parochial.     

Patient-reported outcomes for tension-free vaginal tape-obturator in women treated with a previous anti-incontinence procedure

Our purpose was to evaluate the outcome of a subset of patients that had a tension-free vaginal tape-obturator (TVT-O) placed following a previous anti-incontinence procedure. We performed a retrospective analysis of 27 consecutive women who had a TVT-O placed from January 2004 to December 2007. Patients were given the Patient Global Impression of Improvement (PGI-I) questionnaire starting at the 3-month follow-up. Of 174 women who had a TVT-O placed, 27 (15.5%) had a prior failed anti-incontinence procedure or surgery performed. The mean age was 63.8 years (range 43–87). Mean follow-up was 25.7 months (range 12–47 months). Based on the PGI-I, the overall success rate was 80% (20/25). In the properly selected patients with prior intervention for stress urinary incontinence (SUI), the success rate for TVT-O of 80% appears to be comparable to that of patients who never had a previous surgical or minimally invasive treatment for SUI.     

改良TVT-O术治疗女性压力性尿失禁疗效分析

目的探讨经闭孔无张力尿道中段悬吊术（transobturator vaginal tape inside-out,TVT-O）治疗女性压力性尿失禁（stress urinary incontinence,SUI）的初步疗效和手术安全性。方法对压力性尿失禁患者21例行改良TVT-O术,并对手术效果和并发症进行初步的随访研究。结果平均手术时间30min,平均出血量35ml,平均住院天数5．2d。术后尿失禁症状均得到控制或减轻,1例患者出血局部血肿,经保守治疗后好转,随访6～12个月无复发。结论改良TVT-O术治疗女性压力性尿失禁疗效确切,具有手术时间短、创伤小、不损伤膀胱、费用低等优点。     

Clinical and quality-of-life outcomes in women treated by the TVT-O procedure

OBJECTIVES: To objectively assess the success rate at 6 months after tension-free vaginal tape obturator (TVT-O) procedure. To assess subjective success rates, complications, patient satisfaction, and quality of life (QOL). DESIGN: A prospective observational study. SETTING: A tertiary referral urogynaecology practice. POPULATION: A cohort of 100 consecutive women who underwent the TVT-O procedure between March and October 2004. METHODS: The TVT-O technique was performed as described. Three standardised QOL questionnaires were completed preoperatively at 6 months and 12 months. At 6 months, a urogenital history, visual analogue scale score (VAS) for patient satisfaction, uroflow, and urinary stress test were performed. After 12 months, a urogenital history and patient satisfaction verbal analogue score (VeAS) were obtained by telephone interview. MAIN OUTCOME MEASURE: Objective success rate of the TVT-O procedure was measured by negative stress test. Secondary outcomes were subjective success rates at 6 and 12 months, pre- and postoperative comparison of urodynamic parameters, complications, postoperative symptomatology, QOL analysis, and patient satisfaction. RESULTS: Mean follow up was 18.5 months. Objective success rate was 95%. Subjective success rates were 92 and 84% at 6 and 12 months. Complications included recurrent urinary tract infection (six), voiding difficulty (two), persistent groin discomfort (three), haematoma (one), wound infection (one), vaginal tape erosion (one), and urethral irritation (one). Prevalence of de novo urge incontinence was 4.1 and 4.8% at 6 and 12 months. QOL analysis showed significant improvements in QOL scores postoperatively. Visual and verbal analogue scores indicated high patient satisfaction (VAS, VeAS >or= 80%) in 77 and 67% at 6 and 12 months. CONCLUSION: The TVT-O is a safe and effective treatment for female stress urinary incontinence.     

TVT-O对SUI大鼠膀胱尿道结构和功能的长期影响

目的观察由内向外经闭孔阴道无张力吊带术（TVT-0）治疗大鼠女性压力性尿失禁（SUI）模型的长期疗效和研究吊带对膀胱尿道结构功能的影响。方法健康雌性sD大鼠24只，随机分为4组。对照组只游离阴部神经，但不切断；其余三组行双侧阴部神经切断术；假手术组按照TVT-O术操作，但不置入吊带；TVT-0组行标准的TVT-O术。于术后6周，行腹压漏尿点压（ALPP）测定和膀胱测压，取中段尿道、膀胱和双侧肾脏进行组织学检查。结果SUI组ALPP较对照组显著下降（P=0．028），TVT-O使ALPP恢复到对照组水平（P=0．686），各组最大逼尿肌收缩压（MP-det）比较差异无统计学意义（x=^2．204，P=0．531），TVT-O组的膀胱顺应性和膀胱容量显著增加。组织学检查见SUI组尿道横纹肌明显萎缩变薄，TVT-O组中段尿道和阴道间的胶原含量比其余三组显著增加（P=0．043）。各组膀胱壁和上尿路结构无异常改变。结论双侧阴部神经切断术可以建立长期稳定的SUI大鼠模型，TVT-O治疗大鼠SUI安全、长期有效；TVT-O术不影响膀胱的收缩功能，但可以使膀胱容量和顺应性增加。     

TVT-O手术与 A-JUST手术治疗女性压力性尿失禁的临床疗效研究

目的:探讨TVT-O手术和A-JUST手术治疗女性压力性尿失禁(SUI)的临床疗效,为女性SUI的临床手术方案选择提供参考依据。方法:选取2014年5月—2016年12月在我院确诊为SUI的女性患者157例,随机分为两组:TVT-O组(80例)和A-JUST组(77例),对两组患者的一般资料、手术效果、术后生活质量和并发症进行统计分析。结果:两组患者手术时间和术中出血量比较,均无统计学差异(P>0.05)。与TVT-O组相比,A-JUST组住院天数、留置尿管时间和大腿内侧牵扯痛发生率明显要少,差异均有统计学意义(P<0.05)。两组患者术后I-QOL评分均逐渐提高,但同期得分相比无统计学差异(P>0.05)。两组患者手术后治愈率和改善率均无统计学差异(P>0.05)。两组患者远期并发症主要是排尿困难、漏尿和尿潴留,但发生率均无统计学差异(P>0.05)。结论:A-JUST术与TVT-O术治疗女性SUI均有良好的临床疗效。A-JUST术具有住院时间短、导尿时间和术后大腿内侧牵扯痛率低的优势,值得临床推广。