Complications of male incontinence surgery

Urinary incontinence can result following surgical treatment of benign prostatic hyperplasia or prostate cancer and has a significant impact on quality of life. The artificial urinary sphincter and male sling are the current surgical treatment options for post-prostatectomy incontinence. It is important that physicians and patients are aware of the potential risks associated with these procedures. This article discusses the recognized complications of the artificial urinary sphincter and the male sling with respect to temporal occurrence (intraoperative, early postoperative, and delayed or long term).     

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.     

Urinary incontinence: when to refer for procedural therapies

Urinary incontinence is not life-threatening but rather is a social problem for older women. Therefore, 'patient selection' for a surgical intervention is up to the patient. The physician's role is to educate patients about available procedures, including potential complications and success rates. Invasive treatments for stress incontinence include retropubic or needle suspension, sling procedures, injections of periurethral bulking agents such as collagen, and implantation of an artificial sphincter. An electrical nerve stimulation device has recently been approved for urge incontinence. Many consumer advocacy groups provide support and patient education on incontinence.     

Experience with Tension‐free Vaginal Tape (TVT)‐SECUR for Female Stress Urinary Incontinence

Objectives: Tension‐free vaginal tape (TVT)‐SECUR is a technique specifically designed to place a short suburethral mesh sling for the treatment of female stress urinary incontinence (SUI). The aim of the technique is to decrease surgical morbidity. We report our experience of applying this technique on 10 patients. Methods: From June 2007 to July 2007, 10 female patients with SUI underwent TVT‐SECUR placement operation. The sling was inserted in a suprapubic direction over the inner surface of pubic bone (U‐shaped technique). Nine of the patients underwent videourodynamic study (VUDS). The maximal bladder neck decent distance (MBND) by abdominal straining was determined. We identified intrinsic sphincter deficiency (ISD) as a valsalva leak point pressure lower than 60 cm H₂O and hypermobility as MBND more than 2 cm. Results: Two patients had pure ISD, three had hypermobility, and four had both ISD and hypermobility. All patients remained continent for first month after surgery. SUI recurred in five of nine patients at an average of 2.5 months. The recurrence appeared in all three groups of patients. The recurrent SUI was so severe that three patients required repeat surgery using percutaneous prolene tape sling. After surgery, no further SUI was noted in the three patients. During surgery the TVT‐SECUR sling was found to have firmly adhered to perivesical tissue rather than to the pubic bone. Conclusion: Our experience shows that the current design of the TVT‐SECUR results in unpredictable outcomes. Some placed slings may migrate away from the inner surface of the pubic bone. To act as a reliable “hammock”, the sling must be securely fixed on immobile structures independent from the bladder/urethra.     

Management of Recurrent Stress Urinary Incontinence After Failed Mid-Urethral Sling Placement

Purpose of Review

Our objective is to review the current literature on recurrent stress urinary incontinence after mid-urethral sling placement, focusing on evidence-based management considerations for this complex clinical problem.

Recent Findings

Conservative, minimally invasive surgical therapies are currently available for management of persistent or recurrent SUI after a previous mid-urethral sling (MUS).

Summary

Our review of the literature does not show a clear benefit of one approach over others and emphasizes that the ideal management for these complex patients should be determined using an individualized approach with a detailed discussion of patient symptoms, past surgical history, and goals. For symptomatic patients who are surgical candidates and desire intervention, trans-urethral bulking agents, repeat retropubic (RP) MUS, or salvage autologous pubovaginal (PV) sling appear to be the most well-described management strategies.

     

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.     

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.     

Detrusor Underactivity in Men Following Radical Retropubic Prostatectomy - Prevalence, Importance and Evaluation

Stress Urinary Incontinence is a common morbidity after radical prostatectomy. It is estimated that up to 6 % of men who undergo radical prostatectomy will subsequently have a procedure for correction of stress urinary incontinence. Over the past two decades, the interest in treating male stress incontinence with sling procedures has increased. The success of sling surgery is predicated on ventral urethral compression to maintain continence while continuing to allow spontaneous voiding. In some men however, the increased urethral resistance provided by the sling can precipitate urinary retention, specifically those with detrusor underactivity. This paper will review: a) the difficulty in defining detrusor underactivity in men after radical prostatectomy; b) the incidence of urodynamic detrusor underactivity after radical prostatectomy; and c) the potential importance of this finding in men seeking treatment for post radical prostatectomy incontinence.     

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.     

Focusing on long-term complications of mid-urethral slings among women with stress urinary incontinence as a patient safety improvement measure: A protocol for systematic review and meta-analysis

Background:There are 3 different types of mid-urethral sling, retropubic, transobturator and single incision performed for women with stress urinary incontinence. Prior studies comparing these three surgeries merely focused on the successful rate or efficacy. But nevertheless, what is more clinically important dwells upon investigating postoperative complications as a safety improvement measure.Methods:A systematic review via PubMed, Ovid, and the Cochrane Database of Systematic Review and studies were applied based on the contents with clearly identified complications. Selected articles were reviewed in scrutiny by 2 individuals to ascertain whether they fulfilled the inclusion criteria: complications measures were clearly defined; data were extracted on study design, perioperative complications, postoperative lower urinary tract symptoms, postoperative pain, dyspareunia, and other specified late complications.Results:A total of 55 studies were included in the systemic review. Perioperative complications encompassed bladder perforation, vaginal injury, hemorrhage, hematoma, urinary tract infection. There were postoperative lower urinary tract symptoms including urine retention and de novo urgency. Furthermore, postoperative pain, tape erosion/ extrusion, further stress urinary incontinence surgery, and rarely, deep vein thrombosis and injury of inferior epigastric vessels were also reported.Conclusions:Complications of mid-urethral sling are higher than previously thought and it is important to follow up on their long-term outcomes; future research should not neglect to address this issue as a means to improve patient safety.     

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.     

Is there still a place for the pubovaginal sling at the bladder neck in the era of the midurethral sling?

Perhaps the most significant advance in the modern-day surgical management of stress urinary incontinence is the introduction of the tension-free midurethral sling procedures. Based on a theory of anatomy and function, which emphasizes the importance of the midurethra in maintaining continence during stress, these minimally invasive procedures are being used widely in the surgical treatment of stress urinary incontinence. As surgeons continue to experience excellent early results, a major concern is defining the role of the traditional pubovaginal sling placed at the bladder neck. In addition to the obvious indications to consider a more traditional sling procedure (markedly atrophic vaginal wall or situations that may promote sling erosion), are there other clinical scenarios in which there still is a role for the traditional pubovaginal sling? Several clinical conditions that warrant consideration of a traditional sling procedure are presented in this review. Based on the mechanism of action and clinical data demonstrating decreased efficacy of midurethral sling procedures, we propose that a traditional pubovaginal sling be considered in the following clinical conditions: lack of urethral mobility, mixed urinary incontinence, concomitant urethral reconstruction, and after a failed sling procedure. In the absence of randomized control trials, we present evidence that makes a case for consideration of the traditional sling procedure in these complex clinical conditions.     

Bladder Outlet Obstruction After Incontinence Surgery

Stress urinary incontinence (SUI) is said to effect up to 80 % of all women who complain of some type of urinary leakage. As education about the diagnosis and treatment of SUI becomes more widespread, there is a need for understanding the efficacy and potential complications of the therapies used to treat this condition. It is widely accepted that the gold standard for treatment of SUI is mid-urethral sling (MUS). One significant complication of the MUS procedure is subsequent bladder outlet obstruction (BOO). We review the incidence and etiology of BOO following MUS and hope this document can be used as a guide for identifying patients who may be affected by postsurgical BOO. Additionally, we discuss modalities for achieving a timely and accurate diagnosis and highlight recent evidence regarding the various applications of urodynamic studies, when concerned for BOO. Lastly, various managements of this complication are discussed. This chapter serves as a comprehensive overview of BOO after incontinence procedures, highlighting the recent research contributions, which have enhanced our understanding of this potential complication when treating SUI.     

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.     

Rectosigmoidal bladder utilizing an intussuscepted ileal segment: a surgical technique for urinary diversion

A novel technique of urinary diversion was designed by interposition of an intussuscepted ileal segment between the ureters and the rectosigmoidal pouch, thus preventing ureteral reflux as well as stenosis at the uretero-enteric anastomosis, possible occurrence of urocolonic carcinoma, and frequent evacuation or incontinence. Since all the procedures were limited to the lower abdominal cavity, the surgical invasiveness was compatible with that of an ileal conduit. Our early experience in 15 patients showed that this technique can be considered for those in whom the urethra is not available.     

Management of Stress Urinary Incontinence in the Neobladder Patient

Considering the intent for provision of near-normal urinary function with an orthotopic diversion, issues with voiding dysfunction and urinary incontinence manifest substantial impact on quality of life for neobladder patients. Following appropriate functional and anatomic evaluation, often employing cystoscopy and urodynamics, multiple treatment strategies are available for treatment of stress incontinence in this complex patient population. Conservative modalities including pelvic floor physical therapy, behavioral therapies, and general education regarding neobladder diversion are foremost. Pharmacologic therapies may be suitable in select circumstances. Minimally invasive treatments such as transurethral bulking agents can provide improvement for women with stress incontinence following orthotopic diversion; however the risk profile may preclude use in many patients. Midurethral tape technologies, including transobturator and single incision slings, represent a comparatively recent iteration of implements to be considered. The pitfalls of fascial pubovaginal sling include navigation of complex anatomy combined with a high rate of urinary retention. In men, artificial urinary sphincter continues to exemplify an effective continence procedure following neobladder diversion with only a modestly elevated complication profile in these high risk patients. Male sling technologies are additionally gaining appreciation as an option for treatment of sphincteric dysfunction following orthotopic neobladder and forgo several drawbacks associated with artificial sphincter placement.     

Postprostatectomy incontinence: Pathophysiology and management

Postprostatectomy incontinence in men is a devastating condition impacting the quality of life profoundly. Various types of male sling procedures have been introduced over the years. The bone-anchored male sling appears to be effective and safe in intermediate-term follow-up. It is certainly more effective than collagen implant and may provide an alternative treatment option in patients with mild to moderate incontinence. In the short term, other novel procedures seem promising. In spite of new technology, the artificial urinary sphincter continues to provide high patient satisfaction and cure rates.     

Lower urinary tract and bowel dysfunction after incontinence and prolapse interventions

The incidence of anti-incontinence procedures and surgery for prolapse repairs has increased significantly over the past decade. As more clinicians have embarked on performing these surgeries using new techniques and variations on traditional repairs, complications are starting to be recognized. We review the literature, focusing on postoperative lower urinary tract and bowel dysfunction following surgery for incontinence and pelvic prolapse. We performed a comprehensive review of the literature on interventions for urinary incontinence and pelvic prolapse using MEDLINE and resources cited in those peer-reviewed papers. Postoperative voiding dysfunction including symptomatic bladder outlet obstruction, de novo urgency and urge incontinence, and recurrent stress urinary incontinence appear to be the most common voiding issues after anti-incontinence surgery, with rates varying based on the type of sling used. Bowel dysfunction following prolapse surgery can occur after rectocele repair and sacrocolpopexy or other apical repair and may vary based on the surgical technique and graft reinforcement used. Success rates for incontinence and prolapse repairs remain stable. With the introduction of new techniques, it is important to consider potential postoperative bladder and bowel effects so that clinicians may counsel their patients appropriately prior to intervention.     

The effect of age on outcomes of sling surgery for urinary incontinence

OBJECTIVES: To measure the effect of patient age on outcomes of sling surgery for stress urinary incontinence.
DESIGN: Analysis of Medicare claims data.
SETTING: Analysis of the 1999 to 2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services on a 5% national random sample of beneficiaries.
PARTICIPANTS: Women who underwent sling procedures between July 1, 1999, and December 31, 2000, were identified according to Common Procedural Terminology, Fourth Edition , code 57288 (sling operation for stress incontinence). Subjects were tracked for 6 months before surgery to identify preoperative comorbidities and for 12 months after surgery to assess short-term complications. Subjects were stratified for analysis at age 75.
MEASUREMENTS: Bivariate analyses were conducted with patients stratified at age 75, and multivariate analyses were also conducted to identify the independent effects of patient age and comorbidities on outcomes.
RESULTS: A total of 1,356 procedures were performed during the 18-month index period. This extrapolates to 27,120 procedures in all Medicare beneficiaries. At 1 year after surgery, overall outcomes in younger women (aged 65–74) were significantly better than in older women with respect to postoperative urge incontinence (20.0% vs 12.6%), treatment failure (10.5% vs 7.2%), and outlet obstruction (10.5% vs 6.6%). Older age and greater comorbidity were associated with greater risk of nonurological events (e.g., pulmonary embolism and cardiac events).
CONCLUSION: Women aged 75 and older are more likely to experience postoperative urge incontinence, treatment failure, and outlet obstruction after sling surgery. Older age and comorbidities were associated with higher rates of nonurological complications.     

How to Best Predict Success of the Transobturator Male Sling

Although the male sling is a popular and effective option to treat stress urinary incontinence, the reported success rates are highly variable. Detailed knowledge of the factors affecting male sling outcome can improve clinical efficacy and provide realistic expectations for patients. The objective of this article is to review the current literature that identifies factors associated with surgical outcome, with the goal of optimizing pre-operative selection criteria. Since most practitioners prefer the transobturator approach, the retrourethral transobturator sling (i.e., AdVance? sling) is the focus of this review.