Value of Maximum Urethral Closure Pressure in Predicting the Outcome of Tension‐Free Vaginal Tape and Transobturator Tape Procedure

Objectives: The short‐term results for the tension‐free vaginal tape procedure (TVT) and the transobturator tape procedure (TOT) for stress urinary incontinence (SUI) were compared using the preoperative maximum urethral closure pressure (MUCP). Methods: A total of 278 patients treated for SUI was considered: 165 who underwent TVT and 113 who underwent TOT retrospectively. The MUCP in a preoperative urodynamic study before and 3 months after surgery were evaluated. Results: At 3 months after TVT, 159 patients (96.4%) were cured and four patients failed. The mean MUCP of the patients who failed was 22.5 ± 5.3 cmH₂O, which was significantly lower than that among the cured patients (P < 0.007). At 3 months after TOT, 100 patients (88.5%) were cured and seven patients failed. The mean MUCP of the patients who failed was 27 ± 6.3 cmH₂O, which was significantly lower than that among the cured patients (P < 0.001). Furthermore, the mean MUCP among the patients who were cured after TOT was significantly higher than that among the patients who were cured after TVT (P < 0.01). A further analysis using a ROC curve indicated that the MUCP value in the successful patients after TVT was ≧ 24 cmH₂O and that in the failures after TOT was ≦ 30 cmH₂O with selection sensitivity at 80%. Conclusion: These results suggest that the failure cases after TVT or TOT are often found in SUI with a low MUCP and that TVT might be superior to TOT in SUI with a MUCP ≦ 30 cmH₂O.     

Simultaneous Treatment of Female Urethral Diverticulum and Stress Urinary Incontinence with Urethral Diverticulectomy and Suburethral Synthetic Mesh Sling

Objectives: Pubovaginal fascial sling along with urethral diverticulectomy has been advised as the most appropriate anti‐incontinence procedure for female stress urinary incontinence (SUI) with concomitant urethral diverticula (UD). We believe that suburethral synthetic mesh tape sling can also be safely used in some patients with concomitant SUI and UD. Herein, we present our experience for simultaneous treatment of UD and SUI with urethral diverticulectomy and suburethral synthetic mesh tape sling. Methods: From 2003 to 2008, there are three patients with UD and SUI in our institution. They received transvaginal urethral diverticulectomy and suburethral synthetic mesh tape sling simultaneously. Videourodynamics was done before and three months after the surgery. Results: Preoperative pelvis magnetic resonance imaging and videourodynamic study showed UD over distal urethra and SUI in all three patients. Urinalysis disclosed mild pyuria in two of the patients, and they both received intravenous antibiotics treatment to eradicate the infection prior to the surgery. They all underwent urethral diverticulectomy with suburethral synthetic mesh tape sling. The postoperative videourodynamic study showed no recurrence of UD and SUI. With a mean follow up of 33.3 months, there was no infection or exposure of synthetic mesh tape. Conclusions: In patients with UD and SUI, suburethral sling using synthetic mesh can be as effective and safe as facial sling in selected patients.     

Severe Thigh Abscess Two Years after Transobturator Sling Operation

Objectives: Tension‐free vaginal tape has gained large popularity owing to the ease of the procedure and its effectiveness. These procedures were initially thought to rarely involve any significant morbid complications. The transobturator tape (TOT) procedure reproduces the natural suspension similar to the tension‐free vaginal tape with a reduction in potential bladder, bowel, and vascular complications by the retropubic approach. However, the TOT procedure is not risk‐free when improperly performed. We report a rare case of abscess formation after TOT. Methods: A 45‐year‐old woman was admitted to the orthopedic department with the chief complaint of right side thigh pain and swelling. Pelvis MRI showed abscess formation and inflammatory changes extending into the soft tissues and muscles between the right gracilis and adductor femoris. During incision and open drainage, the remnant mesh could not be located. On urologic consult, the pelvic examination located the remnant mesh to the right upper vaginal wall. Our patient underwent excision of the mesh material. Results: She had significant improvement of the leg pain and was discharged home in good condition on postoperative day 7. Ultimately, the treatment for this complication was the removal of the mesh. Conclusion: Treatment for thigh abscess after TOT was the removal of the mesh. All patients should be counseled about this potential complication.     

Different sling procedures for stress urinary incontinence: A lesson from 453 patients

Several midurethral sling (MUS) procedures, such as tension-free vaginal tape (TVT), TVT obturator (TVT-O), tension-free vaginal tape SECUR (TVT-S), and pubovaginal sling (PVS), have been used for the treatment of female stress urinary incontinence (SUI); however, which method is best for a particular patient group is not known. This study aimed to identify the best rationale for choosing the optimal MUS procedure for each patient. In total, 453 consecutive female patients with SUI who were treated with MUSs in West China Hospital of Sichuan University from September 2003 to September 2011 were enrolled in this study. All the patients underwent comprehensive pre-, intra-, and postoperative evaluations, including collection of demographic information, pelvic examination, and urodynamic testing, and operation-related complications were recorded. The Incontinence Quality of Life questionnaire was also completed. Under local or general anesthesia, 105 cases were treated with TVT, 243 with TVT-O, 90 with TVT-S, and 15 with PVS. Patients with different profiles in terms of age, symptom duration, concomitant procedures, urodynamic parameters, and pelvic organ prolapse (POP) quantification score were treated successfully; the body mass index did not differ significantly among the various treatment options. The cure and improvement rates were similar among the treatment groups: 97.14% (102/105) in TVT, 100% (243/243) in TVT-O, 98.89% (89/90) in TVT-S, and 100% (15/15) in PVS. Only minor complications were experienced by the patients. In conclusion, each MUS procedure was observed to be safe and effective in different subpopulations of patients, and the results suggest that appropriate patient selection is crucial for the success of each MUS procedure.     

Secondary Transobturator Tape Procedure after Combined Pelvic Organ Prolapse Repair

A 66‐year‐old female who underwent a partial urethrectomy complained of severe incontinence due to intrinsic sphincter deficiency. Bone anchor surgical technique was performed, but in 3 years, serious pelvic organ prolapse had occurred. Consequently, anterior and posterior tension‐free vaginal mesh operation was planned. Preoperative urodynamic examination predicted postoperative stress incontinence, and concurrent transobturator tape (TOT) surgery was performed. After 3 months, stress incontinence reoccurred, and secondary TOT was performed. Relapse was probably caused by dislocation of the first TOT towards the bladder neck. Thus, the secondary TOT was placed distal to the initial tape towards the external urethral meatus, and proper tension was applied. After the operation, stress incontinence was cured. Thus, a second TOT procedure, with proper positioning and tensioning, can effectively cure stress incontinence that occurs after an initial TOT procedure.     

TVT and TOT: a comparison between these two techniques based on our clinical experience

AIM OF THE STUDY: A retrospective evaluation and a comparison of results from two minimally invasive surgery techniques that we adopted for the treatment of SUI. MATERIALS AND METHODS. In this study we evaluated 113 selected patients who underwent SUI minimally invasive surgery from 1-1-2000 to 31-12-2007. 87 patients underwent epidural anesthesia. 26 local anesthesia. In Group A (TVT) 61 patients were enrolled, mean age 57.6 (±22). 43 patients (70%) were on menopause. In Group B (TOT out-in) 52 patients were enrolled (for 34 of them we used the Obtape? sling while for 18 the Obtryx? one), their mean age was 58.5 (±20.5) and 39 patients (75%) were on menopause. Patients from both groups did not undergo any past previous urogynecological surgery and suffered from stress urinary incontinence with cervico-urethral hypermobility butno other associated pathology. The pre-operative work-up included an evaluation of patients based on ICS guidelines. RESULTS. Group A (TVT) - mean follow-up 66.3 months, dry patients 53/61 (86.8%). Bladder perforations resolved by catheterization 3/61 (5%). Transient voiding dysfunction 14/61 (22.8%). "De novo" urgency 8/61 (13%). One patient on self-catheterization due to persistent urinary retention underwent a single-side section of the sling with spontaneous micturition and complete continence recovery. Group B (TOT out-in) - mean follow-up 35.5 months, dry patients 43/52 (82%). 4 patients (7.6%) complained oftransient voiding dysfunction, 5 patients (9.5%) for "de novo" urgency, 1 patient underwent a sling removal due to vaginal erosion 4 months after surgery (Obtape?).     

Tension-free vaginal tape for the treatment of stress urinary incontinence in geriatric patients

OBJECTIVE: To evaluate the safety and efficacy of tension-free vaginal tape (TVT) for the treatment of stress urinary incontinence (SUI) in geriatric patients. PATIENTS AND METHODS: Fifty-one women, aged 65-80 (mean 72.3) years, underwent a TVT procedure for genuine SUI from 2001 to 2004. A urodynamic test together with uroflowmetry were performed. The patients' SUI bother score was assessed using a visual analog scale (VAS). RESULTS: The mean operative time was 25 (range 14-29) min and mean hospitalization time was 1.2 (range 1-2) days. Bladder perforation occurred in 3 cases (5.8%) and was managed conservatively. Pre- and postoperative maximum flow rate were not significantly different (p > 0.05). The patients' SUI bother score estimated by the VAS was statistically significantly improved (p < 0.0001). After a mean follow-up of 35.6 (range 14-60) months, 49 patients (96%) had no SUI, while 2 patients (3.9%) had persistent SUI. Also, during the follow-up 5 patients (9.8%) were diagnosed with de novo urgency due to detrusor overactivity and 1 patient (1.9%) had persistent dysuria that was resolved with urethrolysis. CONCLUSIONS: SUI in elderly women can be safely treated with the TVT procedure in the vast majority of the patients. However, bladder perforation during surgery and de novo urgency postoperatively should be taken into account.     

Evaluation and Treatment of Persistent Stress Urinary Incontinence after Male Anti-Incontinence Procedure – AUS or Sling

The two most common anti-incontinence procedures performed for postprostatectomy incontinence (PPI) are placements of the artificial urinary sphincter (AUS) and male sling. While both procedures offer high success rates, 10-30 % of patients after AUS and 20-45 % of patients after male sling require evaluation for persistent PPI. The goals of evaluation for persistent PPI should be to verify the diagnosis of stress urinary incontinence (SUI) and to assess for concurrent bladder dysfunction. If the initial procedure was an AUS, and recurrent intrinsic sphincter deficiency is diagnosed, it is vital to distinguish among mechanical failure, urethral atrophy and erosion. If a repeat sling is considered, it is necessary to verify the degree of intrinsic sphincter deficiency (ISD) and assess for persistent or recurrent proximal urethral mobility. Because of diminished urethral compliance that results from prior AUS or male sling surgery, implantation of an AUS remains the treatment of choice for persistent SUI, as it is the most reliable method of providing the circumferential urethral compression necessary for adequate coaptation even in the setting of urethral fibrosis.     

Challenge of One‐incision Midurethral Sling for Female Stress Urinary Incontinence: Current Results

As a result of the understanding of the pathogenesis of stress urinary incontinence in females, a tension‐free vaginal tape procedure has been introduced based on integral theory and is now widely used because of its minimal invasiveness and high success rate. Modifications over the last 10 years include changes to mesh type, technique and route of insertion of sling materials. Long‐term efficacy and quality of life data of the different midurethral sling (MUS) procedures are available. However, complications, such as bladder and urethral injury, persistent groin pain, vascular and nerve injury, and voiding difficulty can occur. Recently, one‐incision MUS procedures without tape outlets have been developed to reduce surgical invasiveness and lower the risk of complications. However, few studies have reported the outcomes following one‐incision MUS procedures. The present report reviews studies of one‐incision MUS procedures to determine whether this technique can be used in the place of older techniques. It appears that while one‐incision MUS procedures may be associated with lower complication rates, success rates may also be lower, although the latest results are promising. It takes a long time for the surgeon to become an expert in performing the technique. Proper sling tension and correct surgical plane are very important. At the moment it seems that the one‐incision sling cannot replace older slings. We need to wait for and review the long‐term prospective results of the new and minimally invasive one‐incision sling for the treatment of female stress urinary incontinence.     

Urinary incontinence: sphincter functioning from a urological perspective

Stress urinary incontinence (SUI) is a debilitating disorder caused by malfunctioning of the urethral sphincter. Anatomical and histological properties of the sphincter, its innervation and supporting structures are explained in relation to the closing mechanism of the bladder outlet. Urethral sphincter function is discussed from the passive concept of urethral pressure transmission to the 'hammock theory' and the role of the pubococcygeus muscles. SUI is caused by a combination of intrinsic sphincter deficiency and urethral hypermobility. The difficult interpretation of the parameters in urodynamic investigation to assess intrinsic sphincter deficiency (ISD) and/or urethral hypermobility is discussed. Electromyography (EMG) is valuable in the assessment of the overall urethral sphincter in relation to maneuvers (kinesiological EMG) and at the level of the muscle fiber (needle EMG). The diagnostic potential of circumferential surface EMG in the urethral sphincter is reviewed in relation to the EMG features of ISD.     

Effects of the REMEEX System in Female Patients with Intrinsic Sphincteric Deficiency and Recurrent Urinary Incontinence: 3‐Year Outcomes

Objectives: To evaluate the long‐term outcomes of the REMEEX system (EXternal MEchanical REgulation, Neomedic International, Terrassa, Barcelona, Spain) for the treatment of recurrent urinary incontinence (UI) and intrinsic sphincteric deficiency (ISD). Methods: From August 2006 to September 2007, a total of 30 patients underwent REMEEX system. Patients were categorized into failed UI (Group A, 11 patients) and ISD (Group B, 19 patients). The success rate of patients after surgery was assessed by cure and satisfaction rates postoperatively at follow‐up at 1, 12, and 36 months. Clinical, urodynamic, perioperative, and postoperative data of success rates were analyzed. Results: Total cure rates with REMEEX system(Group A/Group B) were 100.0/94.7% at 1 month and 90.9/79.0% at 3 years. Satisfaction rates were 100.0/89.5% at 1 month and 81.8/68.4% at 3 years in groups A and B. Two patients (6.7%) experienced wound infections. Of these, one patient was treated using intravenous antibiotics and the other had their varitensor removed. Other minimal postoperative complications were immediately resolved. Conclusion: The REMEEX system may be an effective procedure regardless of previous incontinence surgical interventions and ISD. The correct sling tension is easily achieved during the early postoperative period, and when necessary, is able to convert late failures into cures. The problems of recurrent UI during the follow‐up period were also resolved successfully in every case.     

无张力阴道尿道悬吊术治疗老年女性尿失禁六例临床分析

目的 探讨无张力阴道尿道中段悬吊术(TVT)治疗老年女性尿失禁的临床意义和疗效。方法 采用SPRAC吊带系统对6例单纯性压力性尿失禁老年女性进行TVT治疗，分析其疗效及并发症。结果 6例TVT手术均在硬膜外麻醉下完成，平均手术时间31．6min，术中平均出血36．2ml，5例手术后24h内自行排尿，1例合并肥胖和阴道前壁膨出患者留置尿管1周后自行排尿。术后随访10～28个月，5例尿失禁治愈，1例手术后3个月再次发生尿失禁，2例术后伴不同程度的尿频、尿急，1例自觉耻骨后轻度不适。结论 TVT易操作、创伤小、疗效好，对绝经后老年女性合并肥胖和阴道前壁膨出的压力性尿失禁患者治疗有明显疗效。     

The autologous pubovaginal fascial sling: An update in 2019

The contemporary management of stress urinary incontinence (SUI) has seen renewed interest in the use of autologous fascia for the formation of a retropubic suburethral sling. Traditionally, it has been used in only the most severe of incontinence cases, such as those women with intrinsic sphincter deficiency, or in patients requiring concomitant reconstructive procedures. In the current climate surrounding transvaginal mesh, many doctors and patients are shying away from the less morbid synthetic midurethral sling. International literature has demonstrated that the fascial sling is a safe and efficacious procedure for all patients with SUI, adequately treating both urethral hypermobility and intrinsic sphincter deficiency. This paper will discuss the indications, technique, and outcomes of autologous fascial slings. We will explore the use of fascial slings following failed synthetic slings and also the troubleshooting of commonly encountered issues intra‐ and postoperatively.     

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.     

Patient Reported Goal Achievement Following the Midurethral Sling Procedure for Female Stress Urinary Incontinence

Objectives: Patient perspective is very important for evaluating surgical outcomes. We investigated patient reported goal achievement, overall satisfaction and objective outcome following the midurethral sling (MUS) procedure for female stress urinary incontinence (SUI). Methods: The study prospectively enrolled 88 SUI patients who underwent the MUS procedure between August 2006 and December 2006. Patient examination included medical history, physical examination and an urodynamic study prior to surgery. Before surgery, patients were shown a list and asked to nominate one goal which they most wanted to achieve with surgery (i.e., the target goal). The goals were classified as: symptom‐related, daily life‐related, personal relationship‐ and emotion‐related, and others. Before and after the surgery, patients completed a Bristol Female Lower Urinary Tract Symptom‐Short Form questionnaire. At 1 year postoperatively, patients were assessed in terms of achievement of the target goal, overall satisfaction and cure rate. Results: At the 1‐year follow‐up, overall target goals were achieved in 90.1% of patients, 82 (93.2%) patients were satisfied with the treatment, and 82 (93.2%) patients were cured. For most patients, the target goals were symptom‐related (47 patients, 53.4%). The patients whose goal achievement was less than overall goal achievement were significantly less satisfied than those who fully achieved their goal, and goal achievement was also related to objective cure. Conclusion: Achievement of patient goals was high and could be a good measure of surgical success following MUS for female SUI.     

Defining Causes for Overactive Bladder Symptoms in Women

Objectives: The aim of the present study was to determine the causes for overactive bladder (OAB) symptoms in women visiting a urological clinic. Methods: We prospectively recruited female patients with OAB symptoms between December 2008 and February 2010. All patients were interviewed for their detailed personal and medical history. All patients completed a 3‐day frequency‐volume chart. Symptom severity was evaluated using the International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS) questionnaires. All patients underwent either conventional pressure‐flow urodynamic studies or video‐urodynamic studies. On the basis of these evaluations, patients were assigned to one of the following categories: idiopathic OAB, stress urinary incontinence (SUI)‐associated, neurogenic bladder, or bladder outlet obstruction (BOO). Results: A total of 108 female patients were recruited into the study. The mean age of the patients was 63.75 ± 14.02 years (range: 23–89). Detrusor overactivity was demonstrated in 55 patients (51%). The differential diagnosis was idiopathic OAB in 51 women (47.2%), SUI‐associated in 46 (42.6%), neurogenic bladder in 13 (12.0%) and BOO in 7 (6.5%). Conclusion: Our study suggests that the causes for OAB symptoms could be defined in half of the women visiting a urological clinic. Among them, SUI was the most common. Moreover, OAB symptoms in women might relate to BOO. Detailed history taking and sophisticated urodynamic studies are required for a substantial group of female patients with OAB symptoms to make the correct diagnosis and provide optimal therapy.     

Use of Injectable Urethral Bulking Agents in the Management of Stress Urinary Incontinence

The use of injectable bulking agents is a well-established approach to management of patients with stress urinary incontinence (SUI). No single bulking agent to date has been shown to be superior or consistently durable in the literature. Novel therapeutic strategies, including the use of injectable, muscle-derived stem cell therapy, have shown promising results in investigational stages. Urethral bulking agent therapy can be helpful in the early management of men with SUI following radical prostatectomy, and in women with SUI due to intrinsic sphincter deficiency, urethral hypermobility, or in the setting of failed midurethral sling placement. Despite their widespread use historically, biocompatible agents have been supplanted in recent years by synthetic agents secondary to their potentially improved durability and nonimmunogenic profiles.     

Efficacy of Synthetic Suburethral Slings in Female Urinary Stress Incontinence with Overactive Bladder

Objectives: The aim of the present study was to investigate the efficacy of synthetic suburethral slings in female stress urinary incontinence (SUI) patients with overactive bladder (OAB). Methods: From May 2002 to April 2005, a total of 295 women with SUI underwent suburethral sling procedure. Of the 295 women, only those who were followed up for at least 12 months were included in the study, yielding 236 patients. The patients were divided into three groups: pure SUI; SUI with OAB dry; and SUI with OAB wet. Telephone questionnaires by were used to evaluate the postoperative improvement of SUI and storage symptoms. Results: There were significant differences in preoperative symptom score, quality of life (QoL) score, and preoperative voided volume among the three groups. There were no significant differences among the three groups in terms of the cure rate for the stress component (group 1, 88.6%; group 2, 86.2%; group 3, 86.7%; P = 0.943). Eighty percent of group 1 patients improved in frequency, but two patients (2.3%) complained of de novo urgency. In group 2, 81.5 and 82.7% improved in frequency and urgency, respectively, but one patient (1.7%) complained of de novo urge incontinence. In group 3, 76.9 and 84.4% improved in frequency and urge incontinence, respectively. Conclusion: Suburethral slings are simple, safe and highly effective in treating SUI with OAB.     

Metallic stent deployment in endosonography‐guided biliary drainage: Long‐term follow‐up results in patients with bilio‐enteric anastomosis

Background and Aim: Although reports on endosonography‐guided biliary drainage (ESBD) have been increasing, only a few reports on deployment of a self‐expandable metal stents (SEMS) have been reported. The aim of the present study was to evaluate the safety and efficacy of SEMS deployment in ESBD. Methods: Of 42 patients who underwent ESBD during the period from January 2007 to August 2011, 21 patients with unresectable malignant biliary obstruction in whom SEMS deployment had been attempted were included. In the first session, a plastic stent or SEMS was placed in a bilio‐enteric anastomosis (BEA) method. SEMS was deployed with the one‐step technique or with replacement of a plastic stent with a SEMS in the second session. The technical success, early and late complications, and stent patency of SEMS were evaluated. Results: One‐step SEMS deployment was attempted in seven patients, and SEMS was deployed with stent exchange in 14. SEMS deployment was successful in all patients without any complications. Finally, SEMS was placed in a BEA method in 16 patients (extrahepatic bile duct, 13; intrahepatic bile duct, three), and with antegrade deployment in five. Late complications occurred in three patients who underwent deployment of SEMS in a BEA method (stent obstruction in two and reflux cholangitis in one). The mean stent patency period was 433 days. Conclusions: As SEMS deployment in ESBD is safe and provides long stent patency, a SEMS seems to be the stent of choice in ESBD for patients with unresectable malignant biliary obstruction in whom long survival is expected.     

Stromal Cell‐Derived Factor 1α Induces Accumulation of Intraveneously Administered Marrow‐Derived Stromal Cells in the Partially Obstructed Rat Bladder

Objectives: We investigated the time course of the stromal cell‐derived factor 1α (SDF1α) expression and behavior of intravenously administered bone marrow‐derived stromal (BMS) cells in the urinary bladder of partial bladder outlet obstruction (PBOO) rats. Methods: Study 1: Recombinant SDF1α or saline was directly injected into the bladder wall of female rats followed by intravenous administration of BMS cells isolated from green fluorescent protein (GFP) transgenic rats. The bladder was examined with immunohistochemistry to determine whether SDF1α would enhance migration of BMS cells to the bladder. Study 2: Following surgery of PBOO or sham in female rats, bladders were removed on days 1–14, and expression of hypoxia inducible factor 1α (HIF1α) and SDF1α were examined with real‐time polymerase chain reaction (PCR) to determine if PBOO preferentially increased their expression. Study 3: Female rats underwent PBOO or sham surgery followed by intravenous administration of GFP‐positive BMS cells. Bladders were examined with immunohistochemistry on days 1–14 to determine whether BMS cells preferentially accumulated in the bladder. Results: BMS cells were accumulated in the injection site of SDF1α but not saline in the bladder. SDF1α and HIF1α increased at day 1 after PBOO compared to sham. More BMS cells accumulated in the bladder of PBOO on day 1, and some BMS cells expressed smooth muscle phenotypes by day 14. Conclusion: SDF1α induced with ischemia/hypoxia due to PBOO is implicated in the accumulation of BMS cells in the bladder and regeneration of the bladder for PBOO.