TVT与TVT-0治疗女性压力性尿失禁的疗效比较

目的比较经阴道无张力尿道吊带术(TVT)与经闭孔阴道中段尿道吊带术(TVT-O)治疗女性压力性尿失禁的疗效和安全性,探讨手术对于患者生活质量的影响。方法 87例压力性尿失禁患者按手术方式分为两组,TVT组46例,TVT-0组41例,分别行TVT术和TVT-O术治疗。术后采用自制问卷对两组患者治疗效果以及手术前和手术后6个月~1年的生活质量进行评定。结果两组手术时间分别为(26.2±4.6)min和(20.6土3.1)min,TVT组长于TVT-O组,差异具有统计学意义(P0.05)。两种方法均有效改善患者尿失禁症状,两组治愈率及并发症发生率比较差异均无统计学意义(P0.05);手术后两组患者的情绪、睡眠、饮食和社交活动情况均较术前有明显改善(P0.05),而性生活方面改善不明显。结论 TVT及TVT-0治疗女性压力性尿失禁的疗效及安全性相似,均能有效提高女性患者的生活质量。     

Low incidence of post-TVT genital prolapse

Tension-free vaginal tape (TVT) is a well established surgical procedure for the treatment of female urinary stress incontinence. The operation, described by Ulmsten in 1995, is based on a midurethral Prolene tape support. TVT is accepted as an easy-to-learn and safe, minimally invasive surgical technique. Postoperative genital prolapse has been described following the Burch technique, as well as other surgical methods for the correction of female stress urinary incontinence. The aim of this analysis was to evaluate the occurrence of this specific complication in relation to TVT. Of 314 patients undergoing TVT and followed for up to 50 months only 1 suffered genital prolapse, with de novo grade 2 cystocele, rectocele and uterine prolapse, diagnosed 3 months after the operation. This is the first reported case of genital prolapse following TVT.     

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.     

Pelvic organ prolapse surgery with and without tension-free vaginal tape in women with occult or asymptomatic urodynamic stress incontinence: a randomised controlled trial

Introduction

We set out to determine if insertion of a retropubic tension-free vaginal tape (TVT) sling at the time of pelvic organ prolapse surgery improves continence outcomes in women with pre-operative occult stress incontinence (OSI) or asymptomatic urodynamic stress incontinence (USI).

Methods

We conducted a randomised controlled study of prolapse surgery with or without a TVT midurethral sling. The pre- and post-operative assessment at 6 months included history, physical examination and urodynamic testing. Quality of life (QOL) and treatment success was assessed with the UDI-6 SF, IIQ-7 SF and a numerical success score. The primary outcome was symptomatic stress urinary incontinence (SUI) requiring continence surgery (TVT) at 6 months. Long-term follow-up continued to a minimum of 24 months. Secondary outcomes were quality of life parameters.

Results

Eighty women received prolapse surgery alone (n?=?43) or prolapse surgery with concurrent TVT (n?=?37). Six months following prolapse surgery 3 out of 43 (7 %) patients in the no TVT group requested sling surgery compared with 0 out of 37 (0 %) in the TVT group (ARR 7 % [95 %CI: 3 to 19 %], p?=?0.11). After 24 months there was one further participant in the no TVT group who received a TVT for treatment of SUI compared with none in the TVT group (4 out of 43, 9.3 % versus 0 out of 37; ARR 9.3 % [95 %CI: ?1 to 22 %], p?=?0.06). Both groups showed improvement in QOL difference scores for within-group analysis, without difference between groups.

Conclusion

These results support a policy that routine insertion of a sling in women with OSI at the time of prolapse repair is questionable and should be subject to shared decision-making between clinician and patient.     

Quality of life assessments in women operated on by tension-free vaginal tape (TVT)

The aim of the study was to evaluate quality of life (QOL) prospectively in women who undergo tension-free vaginal tape (TVT) operation for stress urinary incontinence. Sixty-six women who completed QOL questionnaires and a 2-year follow-up examination were included. Improvement of health-related QOL was assessed by the Incontinence Impact Questionnaire-7 (IIQ-7), the Urogenital Distress Inventory-6 (UDI-6), and two questions regarding patient satisfaction and de novo urge incontinence. Prior to surgery, patients complained most of stress symptoms followed by physical activities and emotional health. Postoperatively IIQ-7 and UDI-6 as a whole and all seven domains improved significantly (p<0.001). Scores of IIQ-7, UDI-6, and seven domains did not differ between the adult and the elderly groups. Of the patients 88% were much satisfied or satisfied with surgical outcomes. Incidence of de novo urge incontinence was 12%. It is concluded that the TVT procedure significantly improved health-related quality of life.The authors listed above wrote this contribution on behalf of the Tension-free Vaginal Tape Trial GroupEditorial Comment: This study adds to the body of literature on the efficacy of the TVT procedure. Using quality of life instruments 88% of the patients were much satisfied or satisfied with surgical outcomes. Incidence of de novo urge incontinence was 12%. The biggest deficiency of the study was that follow-up was only available on 66 of 161 women     

The influence of age on quality of life outcome in women following a tension-free vaginal tape procedure

PURPOSE: Tension-free vaginal tape (TVT) has been introduced and demonstrated to be an effective treatment for stress urinary incontinence. Improved general health in the elderly population has led to a greater number of patients seeking surgical treatment for incontinence. We evaluated the impact of TVT on quality of life in elderly patients, defined as age 70 and older. MATERIALS AND METHODS: We prospectively evaluated 67 patients with genuine stress incontinence differentiated by age into 2 groups, namely 21 who were 70 years and older, and a control group of 46 younger than 70 years, with a validated questionnaire. We assessed quality of life changes following TVT for incontinence treatment. RESULTS: At the most recent followup quality of life scores improved significantly in the 2 groups (p <0.05). Stress incontinence improved significantly in the 2 groups (p <0.05). CONCLUSIONS: TVT is effective in each group. It is a viable treatment option to improve quality of life in older women with stress urinary incontinence.     

The prevalence of voiding difficulty after TVT,its impact on quality of life,and related risk factors

Objective: To determine the prevalence of voiding difficulty (VD), quality of life, and related risk factors after tension-free vaginal tape (TVT). Design: Prospective cohort study in 703 women with a TVT procedure for stress urinary incontinence. Main outcome measures: VD stated by women, Urogenital Distress Inventory (UDI-6) question 5 (difficulty in emptying the bladder), maximum flow rate, postvoid residual urine, necessity of postoperative catheterization, tape division, and impact on quality of life (Incontinence Impact Questionnaire, IIQ-7). Results: Postoperative catheterization (>24 h) was necessary in 11% and tape division in 1.3% of patients. There were 26% of women who stated VD and 25% reported moderate to great impairment on the UDI-6 after 36 months. While the negative impact on the outcome of TVT in women with abnormal voiding compared to women without is higher, the impact decreased significantly after TVT, implying a considerable improvement in quality of life. Pre-operative existing voiding difficulty and concomitant prolapse surgery were independent risk factors. Conclusions: Symptoms of VD occurred after TVT and caused lesser improvement in quality of life.     

Sexual function after tension-free vaginal tape (TVT) for stress incontinence: results of a mailed questionnaire

In a retrospective study we evaluated sexual function after tension-free vaginal tape (TVT) placement for urinary stress incontinence based on responses to a mailed questionnaire at least 3 months after the operation, to a maximum of 1 year. From 1999 to 2002, a sexual function questionnaire was mailed to 128 women (and their partners) who had undergone a TVT procedure for genuine urinary stress incontinence, without pelvic organ prolapse or detrusor instability. The questionnaire was returned by 96 women (75%), 69 (72%) of whom reported being sexually active. Mean frequency of intercourse did not change. Overall, 26% described improved intercourse compared to before the operation. Only one patient described worsening of intercourse after the TVT operation because of an increase in her incontinence. Overall, in this study the technique of tension-free vaginal tape as such seems to have no negative impact on sexual function. However, because of its successful outcome on incontinence, it has a positive overall effect on sexual function. The possible causes of postoperative partner discomfort require further investigation.Abbreviations AVWS Anterior vaginal wall suspension - SUI Stress urinary incontinence - TVT Tension-free vaginal tape This study was supported by the Pelvic Floor & Sexuality research group Leiden. Editorial Comment: The impact of urogynecologic surgery on sexual function is unclear. For those who are incontinent with intercourse, cure of incontinence may improve sexual activity at the price of potential damage to the vaginal anatomy. In this study sexual function following the TVT procedure was evaluated. The authors report that sexual frequency was overall unchanged, and many patients felt that intercourse improved. It appears that much of this improvement is probably related to cure of the incontinence rather than any specific features of the TVT. Although the study is flawed by its retrospective design and a long interval between the procedure and the questionnaire, the results overall are reassuring.     

Use of slings in vaginal surgery

The use of slings in the cure of genital prolapse and urinary stress incontinence is justified by the large number of relapses after the classical surgical procedures, especially due to the poor quality of the perineal connective tissue. The ideal sling for vaginal surgery should have certain characteristics, i.e., resistance to infection, bio-stability, bio-compatibility, solidity, interstitial texture, porosity, elasticity, non-aggressive margins. The discussed techniques used in the cure of the stress urinary incontinence are the Tension-free Vaginal Tape (TVT), the Sparc-sling System, the Intra-vaginal sling-plasty tunneller (IVS), and Trans-obturator Tape (TOT). For the cystocele, the under-bladder meshes, either free or fixed to the abdominal wall or to TVT is recommended. For the rectocele, a posterior IVS with a tension-free inter-recto-vaginal prosthesis is suitable, while for the vaginal vault prolapse, hysterocele or isolated elitrocele we discuss the posterior IVS.     

Impact of tension-free vaginal tape on sexual function: results of a prospective study

The purpose of this study was to prospectively assess the impact of a TVT insertion for the treatment of stress urinary incontinence (SUI) on coital incontinence and overall sexual life. Sexually active women with pure SUI and without concomitant pelvic organ prolapse scheduled for TVT procedure completed a sexual function questionnaire at baseline and 6 months after surgery. Fifty-three patients were enrolled. Preoperatively 23 (43.4%) women experienced urine leakage during intercourse, 21 (91%) during penetration and 2 (9%) on orgasm. The objective cure rate for SUI was 98%. Coital incontinence was cured in 20 of 23 patients (87%). Thirty-three (62.2%) women reported no change in sexual function after surgery and 18 (34%) reported an improvement. Of the latter, 17 (94%) were of those cured from coital incontinence. No significant difference in the incidence of dyspareunia was found postoperatively. Two patients (3.8%) reported intercourse to be worse following surgery, one because of a vaginal erosion and one cited de novo anorgasmia as the main reason.     

Tension-free vaginal tape (TVT) for the treatment of occult stress urinary incontinence in women undergoing prolapse repair: a prospective study of 100 consecutive cases

AIMS: Clinically continent women with genitourinary prolapse and occult stress urinary incontinence (SUI) are considered to be at high risk of developing symptomatic SUI once the prolapse is repaired. We studied the efficacy and safety of tension-free vaginal tape (TVT) procedure in preventing postoperative SUI in these women. METHODS: One hundred consecutive women (mean age 66.7 +/- 9.9 years) with significant genitourinary prolapse and occult SUI were prospectively enrolled. Preoperatively, none of the women complained of SUI. However, all had urodynamically-confirmed occult SUI, revealed by repositioning of the prolapse. Surgical intervention was comprised of transvaginal prolapse repair and prophylactic TVT procedure. Main outcome end points included operative morbidity, postoperative SUI, persistent or de novo urge incontinence, and voiding dysfunction. RESULTS: The mean follow-up period was 27 months (range: 12-52 months). There was only one case of technique-related bladder perforation with no adverse outcome. Two other patients had postoperative urinary retention necessitating catheterization for more than 7 days, none of whom required any surgical intervention. Vaginal erosion of the tape was diagnosed in three patients, all of whom were successfully treated by excision of the eroded tape. Two (2%) patients developed urodynamically-confirmed SUI within 1 year postoperatively. However, postoperative urodynamics revealed asymptomatic sphincteric incontinence in 15 (15%) other patients. Thirteen (72%) of 18 patients with preoperative urge incontinence had postoperative persistent urge incontinence. De novo urge incontinence developed postoperatively in 8 (8%) patients. CONCLUSIONS: TVT procedure is effective and safe in patients with occult SUI undergoing prolapse repair. Long-term durability of this procedure is yet to be established.     

同期手术治疗女性压力性尿失禁与盆腔脏器脱垂的临床研究

目的 探讨同期手术治疗女性压力性尿失禁(SUI)与盆腔脏器脱垂(POP)的适应证及治疗效果.方法 回顾性总结16例同期手术治疗SUI与POP患者的病例资料,其中有SUI症状并伴有中度以上阴道前壁膨出的患者12例,主诉阴道脱出物,检查发现子宫中度以上脱垂伴排尿困难4例,术前经查体、尿动力及膀胱造影检查确诊均存在Ⅱ型SUI.盆底修补手术包括Gynemesh网片、Prolift前片及全片植入,抗尿失禁手术采用TVT或TVT-O术,术中先行盆底修补术.结果 随访6～30个月,全部患者获满意效果,达到完全控尿,同时无排尿困难发生,未发现盆底膨出复发.结论 对合并有症状或中度以上POP的SUI患者,应积极同期处理相应的POP,以免加重POP的程度或排尿困难的发生;对单独发生的POP患者,应警惕隐性SUI的可能,同期行相应的控尿手术可避免术后SUI的发生.     

The impact of TVT on sexual function

The aim of this study was to evaluate sexual function in women before and after tension-free vaginal tape (TVT) procedure. In this questionnaire-based study, 100 women undergoing TVT for stress incontinence were assessed preoperatively and 3 months postoperatively using a validated pelvic floor symptoms assessment questionnaire. The incidence and impact of TVT on orgasm incontinence, penetration incontinence, anxiety related to bladder problems during sex, avoidance of intercourse, and overall impact on sex life were assessed. Incontinence during intercourse was reported in 68% of women preoperatively. Following TVT, there were significant reductions in orgasm incontinence, penetration incontinence, anxiety regarding the bladder and sex, avoidance of sex, post-coital infection, and overall impact of lower urinary tract symptoms on sex. There was a non-significant reduction in partner avoidance of sex. TVT significantly improves the overall sex lives of women with stress urinary incontinence. Orgasm incontinence, penetration incontinence, post-coital infections, anxiety, and avoidance of sex are all reduced. This study was conducted at the Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Glossop Road, Sheffield, S10 2SF, UK.     

The basic understanding and clinical results of tension-free vaginal tape for stress urinary incontinence

Since 1994, over 100,000 surgical reconstructions of the female lower urinary tract have been performed worldwide using tension-free vaginal tape (TVT). This technique, which differs from traditional methods, is effective against symptoms of stress urinary incontinence and may be performed as an ambulatory procedure with no need of indwelling catheterization. The primary indication is genuine stress incontinence, but it is also effective as a secondary procedure for relapse after other anti-incontinence measures such as the Burch procedure. The TVT operation was developed according to study results on the mechanisms of urethral closure in women and has become the primary surgical procedure at several Scandinavian clinics for combating genuine stress incontinence in women. It is also useful in reducing symptoms after prolapse repair for combined prolapse and stress incontinence and in cases of mixed stress and urge ("sensory") incontinence. The small incisions and canals involved with the TVT technique minimize surgical trauma and enable it to be performed under local anesthesia. By the same token, it makes fairly small demands on postoperative care and attendant costs. Here we describe the instrumentation, procedure, and risks of this minimally invasive operative technique.     

Concomitant pelvic organ prolapse surgery with TVT procedure

The aim of this study is to evaluate the efficacy and feasibility of concomitant pelvic reconstructive surgery with tension-free vaginal tape (TVT) procedure to treat pelvic organ prolapse women with urodynamic stress incontinence (USI) or occult USI. Seventy-five women with pelvic organ prolapse and diagnosed as USI or occult USI were enrolled in this study. All patients with USI or occult USI underwent TVT treatment under general anesthesia, combined with transvaginal total hysterectomy (VTH), anterior–posterior colporrhaphy (APC), and/or right sacrospinous ligament suspension (SSS) reconstructive surgeries. The subjective assessment was evaluated by using a visual analog scale (VAS) score and a urinary symptomatic questionnaire. The objective assessment was carried out with a 1-h pad test, cough stress test, and urodynamic examination. Of the 75 patients, 35 patients with grade III uterine prolapse underwent VTH and APC, 30 patients with grade IV uterine prolapse underwent VTH, SSS, and APC, and the other 10 patients who had previous hysterectomy with total vaginal vault prolapse underwent SSS and APC. The mean follow-up interval was 25 months (12–42 months). The mean hospitalization was 5.9 days and the mean catheterization time was 3.8 days. The subjective success rate for the treatment of urine incontinence was 88%, and the objective complete cure rate was 84%. The rate of postoperative complications with persistent urinary urgency, de novo detrusor overactivity, dysfunctional voiding, and tape erosion were 50, 8, 12, and 1.3%, respectively. There were no bladder perforations during the TVT procedure and no perioperative complications requiring conversion to laparotomy. Pelvic organ prolapse women with USI or occult USI can be treated by reconstructive surgeries combined with a TVT procedure to treat and prevent postoperative USI.     

Incontinence and Prolapse—An Integrated View

There is a complex interaction of factors contributing to the development of urogenital prolapse and stress incontinence. These aetiological factors are exactly the same for prolapse as for urinary stress incontinence. These factors include pregnancy and childbirth, collagen status, weight, and chronic airways disease while anti-incontinence surgery itself can be a cause of prolapse. Our understanding of why some women develop stress incontinence, others develop prolapse without stress incontinence, and some develop both, is incomplete. However, the identical aetiologies of the two conditions suggest that an integrated approach to managing stress incontinence and prolapse may be beneficial. This paper looks at the advantages offered by some combined techniques including paravaginal repair and slings, combined cystocoele repair and slings, combining tension-free vaginal tape (TVT) and prolapse repair, combining vault prolapse repair with repair of stress incontinence, combined mesh sling, and a number of combined laparoscopic approaches. Although a combined approach to treatment should be beneficial, there is still insufficient evidence to assess which combined approach is best, which materials to use, and which patients to select.     

Long-term results of tension-free vaginal tape for female urinary incontinence: Follow up over 6 years

OBJECTIVE: To describe the long-term outcome of using tension-free vaginal tape (TVT) with and without associated procedures. METHODS: A questionnaire was mailed to a population of 61 women who had undergone TVT surgery more than 6 years ago. Of this population, 41 (80%) had suffered from stress urinary incontinence (SUI). The questionnaire included questions about urinary symptoms, satisfaction and quality of life. The questionnaire was answered by 51 of the 61 women. RESULTS: Mean follow up was 83 months. The women with SUI had a persistent cure rate of 80% with a satisfaction rate of 97%. The cure rate after 6 years was 37% in women with mixed incontinence. Concomitant hysterectomy (relative risks = 0.87) and body mass index (BMI) do not alter the long-term results of TVT procedure. Peroperative bladder injury is not associated with an increased risk of long-term lower urinary tract symptoms (LUTS) or with a decreased satisfaction rate (relative risks = 0.85). CONCLUSIONS: Concomitant hysterectomy, increased BMI and bladder injury do not alter good long-term results of TVT.     

Retropubic versus transobturator tension‐free vaginal tape (TVT vs TVT‐O): Five‐year results of the Austrian randomized trial

Aims

To compare outcomes of the retropubic versus the transobturator tension‐free vaginal tape (TVT vs TVT‐O) at 5 years.

Methods

A total of 569 women undergoing surgery for primary stress incontinence were randomized to receive a retropubic or a transobturator tensionfree vaginal tape (TVT or TVT‐O). Follow‐up at 5 years included clinical examination, urodynamic studies and quality of life. The primary outcome measure was continence defined as a negative cough stress test at a volume of 300 mL. Secondary outcomes included urodynamic parameters, complications and quality of life. ClinicalTrials.gov (NCT 0041454).

Results

Three hundred and thirty‐one patients (59%) were evaluated at 5 years (277 were seen, examined and completed questionnaires; 54 only completed questionnaires). No significant differences were seen in rates of a negative cough stress test (83% vs 76%, respectively), urodynamic parameters and complications. Quality‐of‐life improved significantly in both groups, without significant differences between the groups. Erosion rates were 5.2% and 4.5%, and reoperation rates were 4.1% and 3.2% respectively.

Conclusions

At 5 years, subjective and objective results after TVT and TVT‐O are stable and similar, without statistical significant differences between the procedures. Major long‐term problems appear rare.     

The role of anti-incontinence surgery in management of occult urinary stress incontinence

Combining anti-incontinence and pelvic organ prolapse surgery for patients with occult urinary stress incontinence is controversial. The concern is that some of these patients may remain continent after vaginal prolapse repair making the addition of anti-incontinence surgery unnecessary. However, this can be explained by the fact that the anterior vaginal repair has a curative effect on stress incontinence. Therefore, these patients are denied the more successful anti-incontinence surgery by treating their incontinence with vaginal repair. Once we are able to detect the true cases of occult urinary stress incontinence, all patients should be offered anti-incontinence surgery in combination of vaginal prolapse surgery.     

Quality of life after tension-free vaginal tape surgery for female stress incontinence

OBJECTIVE: To undertake a long-term follow-up evaluation of the quality of life (QOL) of women who had undergone a tension-free vaginal tape (TVT) procedure. MATERIAL AND METHODS: During the period 1995-2001, 970 women with urinary stress incontinence underwent TVT surgery at the Department of Obstetrics and Gynecology, Falun Hospital. A questionnaire was mailed on average 5.7 years after the TVT procedure. Two incontinence-specific QOL instruments--the Incontinence Impact Questionnaire-7 (IIQ-7) and the Urogenital Distress Inventory-6 (UDI-6)--were administered. An additional questionnaire included general questions and questions about chronic diseases that may be associated with urinary incontinence. RESULTS: The mean age at surgery was 58.7 years (range 29-89 years). Of 913 eligible women, 768 (78.9%) responded. Mean IIQ-7 and IDU-6 scores as estimated by the women improved dramatically at follow-up as compared to preoperative values: from 43.7 to 11.5 for the IIQ-7 and from 54.2 to 24.0 for the UDI-6 on a scale from 0 to 100 (p = 0.0001 for both). There were few differences in mean QOL scores even 8 years after TVT surgery, compared to those determined a shorter time after the operation. Women with diabetes, chronic constipation, chronic bronchitis and preoperative recurrent urinary infections had a relative improvement in QOL of the same magnitude as that of the remaining study population. Advanced age was negatively associated with an improvement in QOL scores. CONCLUSIONS: Improvements in measures of QOL after TVT surgery are dramatic and persist for years. Women with concomitant diseases that may be associated with urinary incontinence can be assured that there is a good chance of success with TVT surgery.