Suburethral slingplasty evaluation study in North Queensland, Australia: the SUSPEND trial

OBJECTIVE: To compare the safety and efficacy of three types of suburethral slings for the treatment of urodynamic stress incontinence. METHODS: Following ethics approval, 195 (3 x 65) patients with urodynamic stress incontinence were randomly assigned to undergo suburethral slingplasty with the Tension-free Vaginal Tape (TVT; Gynecare, Ethicon, Somerville, NJ, USA), Intravaginal Sling (IVS; Tyco Healthcare, Mansfield, MA, USA), or Suprapubic Arc Sling (SPARC; American Medical Systems, Minnetonka, MN, USA). The patients were blinded to the type of sling implanted. MAIN OUTCOME MEASURES WERE: (1) operative and short-term complications; (2) pre- and postoperative symptomatology; and (3) pre- and postoperative urodynamic findings. RESULTS: There was a statistically significant increased rate of sling protrusion (13.1% vs. 3.3% and 1.7%; P = 0.04) in the SPARC group when compared to TVT and IVS. Otherwise, there were no significant differences between the groups with respect to the incidences of other operative complications, patients' main subjective outcomes, satisfaction rates, or postoperative urodynamic findings. The overall objective stress incontinence cure rates were 87.9%, 81.5% and 72.4% for the TVT, IVS, SPARC groups respectively (P = 0.11). CONCLUSIONS: All three slings appear quite successful for the treatment of stress incontinence. The SPARC tapes showed more sling protrusion complications and a trend towards lower objective cure rates; probably as a result of the insertion method used in this study which favoured a loose SPARC sling placement. The authors recommend that the SPARC slings be left tighter than TVT, or for the cough test to be carried out.     

The tension-free vaginal tape operation for the treatment of stress incontinence

The tension-free vaginal tape (TVT) operation and similar procedures are the newest development in the surgical treatment of female stress incontinence. In contrast to the Burch colposuspension and abdominovaginal sling procedures, the operation aims at supporting the midurethra and not the bladder neck. The only ongoing prospective randomized trial comparing TVT with the Burch colposuspension, conducted by the UK and Ireland TVT Trial Group, shows comparable 2-year results. The TVT operation is a technically simple procedure with a low rate intraoperative and postoperative complications. This and the good cure rates may make this procedure and similar methods the standard operation for the treatment of primary and recurrent stress incontinence.     

压力性尿失禁不同手术方式治疗的临床效果分析

目的　分析应用阴道无张力尿道悬吊带(TVT)术、经闭孔尿道悬吊带(TOT)术、自体阔筋膜尿道悬吊(Lata)术,以及耻骨后库柏韧带悬吊(Burch)术治疗压力性尿失禁(SUI)术的临床效果。方法　回顾分析103例尿失禁并部分合并子宫、阴道脱垂患者行不同手术治疗的疗效,其中行TVT术53例,行TOT术16例,行Lata术19例,行Burch术15例。结果　术后3个月治愈率, 行TVT、TOT、Lata和Burch术的患者,分别为94% (50 /53)、94% (15 /16)、95% (18 /19)和87% (13 /15);手术时间分别为(28±7)、(16±5 )、( 125±13 )和( 43±6 )min;术后留置尿管时间分别为( 26±3 )、(3±1)、(120±6)和(72±5)h。手术并发症有膀胱穿孔,行TVT术患者2例;术后尿潴留,行TVT术患者1例,行Lata患者2例。结论　4种手术对治疗SUI均有相同的疗效;TVT术和TOT术为微创手术,术后患者康复快,住院和留置尿管时间短,可与子宫、阴道脱垂等手术同时进行;行Burch术可与经腹其他手术同时进行。     

Outcome of the Laparoscopic Two-Team Sling Procedure,Tension-Free Vaginal Tape Insertion,and Transobturator Tape Insertion in Women With Recurrent Stress Urinary Incontinence

ObjectiveAlthough the surgical treatment of primary stress urinary incontinence (SUI) has been well studied, the optimal treatment of persistent or recurrent SUI represents a significant challenge to the surgeon, and there are limited relevant published data. The aim of this study was to document outcome data for various surgical techniques used at our centre for the treatment of recurrent SUI, and to assess the immediate and long-term complications associated with these procedures.MethodsThis retrospective study assessed the outcome of the laparoscopic two-team sling procedure, tension-free vaginal tape (TVT) insertion, and transobturator tape (TOT) insertion in the treatment of recurrent SUI in women. Data collected included patient demographics, urodynamic data, postoperative subjective cure and objective cure (negative cough stress test), and intraoperative and postoperative complications.ResultsForty-six women with recurrent SUI were included in the study: 24 had had laparoscopic two-team sling procedures, 15 had had TVT insertion, and 7 had had TOT insertion. For each procedure, objective cure rates were 91.7%, 73.3%, and 85.7%, respectively, and subjective cure rates were 79.2%, 60%, and 57.1% respectively. In the laparoscopic two-team sling group, one woman developed an infected hematoma and one required surgery for a small bowel obstruction.ConclusionThe laparoscopic two-team sling procedure or TVT or TOT insertion may be used in experienced hands for surgical management of patients with recurrent stress urinary incontinence. We found no statistically significant differences in outcomes between the three groups, possibly because of the small sample size. Larger sample size and longer follow-up within prospective randomized trials are warranted to identify any possible differences.     

Two- and 3-dimensional MRI comparison of levator ani structure, volume, and integrity in women with stress incontinence and prolapse

OBJECTIVE: The aim of this study was to identify imaging markers for genuine stress incontinence and pelvic organ prolapse by using magnetic resonance imaging and reconstructed 3-dimensional models. STUDY DESIGN: Thirty women were studied, 10 with prolapse, 10 with genuine stress incontinence, and 10 asymptomatic volunteers. Axial and sagittal T1 and T2 weighted pelvic magnetic resonance scans were obtained with the patient in the supine position. Source images were measured to determine levator hiatus height, bladder neck to pubococcygeal line, levator plate angle, and perineal descent at rest and maximum Valsalva. Manual segmentation and surface modeling was applied to build 3-dimensional models of the organs. The 3-dimensional models were measured to determine levator muscle volume, shape and hiatus width, distance between symphysis and levator sling muscle, posterior urethrovesical angle, bladder neck descent, and levator plate angle. RESULTS: The 3 groups of subjects were comparable in age, parity, and body mass index. In the control, genuine stress incontinence, and prolapse groups, the menopausal rate was 40%, 60%, and 55% (P =.7). In the same order, significant mean 2-dimensional measures were: resting bladder neck descent of 24, 17, and 3 mm (P <.005), straining levator plate angle of -4.3, -11.5, and -31 degrees (P =.01), straining levator hiatus height of 48.5, 51.1, and 65.3 mm (P <.005), and straining perineal descent of 17.2, 22.5, 27.2 mm (P =.02). Similarly ordered mean 3-dimensional parameters showed levator volumes of 32.2, 23.3, and 18.4 cm(3) (P <.005); hiatus widths of 25.7, 34.7, and 40.3 mm (P <.005); left levator sling muscle gaps of 15.6, 20.3, and 23.8 mm (P =.03), right levator sling muscle gaps of 15.6, 22.5, and 30.8 mm, (P = 0.003), and levator shape (90%, 40%, and 20% dome shaped; P <.005). CONCLUSION: Both 2-dimensional magnetic resonance images and 3-dimensional models yield findings that differ among asymptomatic subjects compared with those with genuine stress incontinence and prolapse. Our 3-dimensional data demonstrate a statistically significant continuum in levator volume, shape, and integrity across groups of asymptomatic, genuine stress incontinence, and prolapse subjects.     

Incomplete bladder emptying after the tension-free vaginal tape procedure,necessitating release of the mesh. A report of three cases

BACKGROUND: The Tension Free Vaginal Tape (TVT) (Ethicon, Inc., Somerville, New Jersey) procedure is a minimally invasive surgical treatment for stress urinary incontinence. Urinary retention is a potential complication that may require release of the tape. CASES: In three cases, prolonged urinary retention occurred after the TVT procedure. Two of the three cases were performed in conjunction with anterior repair. All three patients required surgical release of the tape, which was located at the urethrovesical junction rather than midurethra. All three patients remained stress continent after tape release. One patient developed urge incontinence. CONCLUSION: Excessive tension, as well as tape migration toward the urethrovesical junction, may be the cause of prolonged urinary retention after the TVT procedure. Surgical release of the tape is an effective management approach to this complication.     

Comparison of retropubic and transobturator tension-free vaginal implants for the treatment of stress urinary incontinence

Objective

To compare the perioperative complications, failure rate, operating time, and length of hospital stay associated with 2 minimally invasive suburethral slings in the management of stress urinary incontinence in women.

Methods

Women diagnosed with stress urinary incontinence were treated with tension-free vaginal tape (TVT) or transobturator tape (TOT). The participants were followed for the next 2 years, with scheduled evaluations 6 weeks, then 3, 6, 12, and 24 months after surgery.

Results

Of the 104 participants, 55 were treated with TVT and 49 were treated with TOT. The condition was classified as “cured” in 81.8% of cases in the TVT group and 83.7% in the TOT group, and improvement occurred in 10.9% and 10.2% of cases, respectively. The mean operating time was shorter for patients treated with TOT than for those treated with TVT. There were no significant differences between the groups in terms of perioperative complications (abnormal voiding dysfunction, urinary infections, and de novo overactive bladder). The temporary and permanent urinary obstruction rates in the TVT group were approximately twice those in the TOT group.

Conclusion

Comparable complications and outcomes were observed with TVT and TOT. Tension-free vaginal implants are effective for the treatment of female stress urinary incontinence.     

Free Communications

Tension-free vaginal tape (TVT) is a well-established surgical procedure for treating female urinary stress incontinence. The operation, described by Ulmsten et al. in 1995, is based on a midurethral Prolene tape support. TVT is accepted as an easy-to-learn and safe minimally invasive surgical technique. Bladder perforation with sling material was described as a complication of former surgical methods for correcting female urinary stress incontinence as well as of TVT. The aim of this analysis was to determine whether the use of a straight inserter for identifying and displacing the bladder prior to inserting TVT needles reduces the occurrence of bladder penetration. Out of 524 patients undergoing TVT and followed for up to 68 months, 68 (13%) had TVT bladder penetrations, all of which were diagnosed and corrected during surgery. All but the last 50 patients had a straight inserter introduced during the procedure. The effect of this surgical step is estimated and discussed.     

Résultats comparés du TVT et du TOT en pratique courante

Eighty-five Tension-free Vaginal Tapes (TVT) were compared with 96 Trans-obturator Tape (TOT). We confirm more bladder risk and more imperiosity when TVT was done. Satisfaction in both groups was the same at 2-year follow-up. There were 10 vaginal ulcerations in the TOT group.     

Ideas to make the TVT progress

Because of the bladder injuries risk and subsequent increase of the intervention time due to the bladder integrity checking, many surgeons have abandoned TVT. Based on a demonstrative clinical case, we report a simple, fast and effective method meant to minimize the risk of bladder injuries and to wonder about the mandatory bladder checking by cystoscopy during the TVT sling installation. An infiltration of 1% Xyloca?ne half diluted is carried out in the area laterally to the urethra and the bladder, through vaginal and pubic ways. A 360 ml blue of methylene solution bladder filling may show quickly and safely a bladder injuries occurrence, either a true transfixion or an under mucous route. Using this procedure, TVT technique could be no more dangerous or longer than the TOT technique.     

Qualité de vie après cure d’incontinence urinaire d’effort : comparaison de trois techniques

ObjectivesTo assess the health-related quality of life (Contilife^®) after three surgical anti-incontinence procedures (Tension-Free Vaginal Tape [TVT], Transobturator Vaginal Tape [TOT], and Transobturator Vaginal Tape [TVT-O]).Patients and methodsWe performed a prospective analysis of 90 women (30 TVT, 30 TOT, 30 TVT-0) with genuine stress incontinence pre- and postoperatively at 18 months. The objective cure rate was determined by clinical and urodynamic examination and the subjective cure rate by the Contilife^® questionnaire.ResultsPrior to surgery, patients complained more of effort activities, followed by global well-being. Postoperatively, all domains improved significantly without statistical difference between the three groups and 90% of the patients would advise the intervention to one of their friends.Discussion and conclusionSurgical outcomes vary greatly depending on the methodology of the study. Health-related quality of life seems paramount to decide time of surgery and to evaluate postoperatory results. We have chosen the Contilife^® questionnaire because of its scientific and clinical validity, reliability, responsiveness and linguistic validation. These results confirm that TVT/TOT/TVT-O procedures are a safe and effective surgical method and that they significantly improved health-related quality of life.     

自制蝶型网片吊带治疗老年女性压力性尿失禁的近期疗效观察

目的:探索蝶型网片治疗老年女性压力性尿失禁(SUI)的可行性及疗效。方法:用自行设计的蝶型网片,改进固定方法和部位,对65岁以上老年女性压力性尿失禁患者21例进行治疗。结果:21例手术后尿失禁均得到控制或减轻,经随访3～12月无一例出现尿失禁复发和加重现象。结论:蝶型网片治疗老年女性SUI疗效确切,具有费用低、手术创伤小、不损伤膀胱等优点。     

Successful colposuspension in stress urinary incontinence reduces bladder neck mobility and increases pressure transmission to the urethra

Summary Twenty-nine consecutive patients with stress urinary incontinence were investigated by bead chain urethrocystography (UCG) and single cough urethrocystometry before operation and 8–12 months after a Burch colposuspension producing clinical improvement. The operation significantly elevated the bladder neck and reduced its mobility during acute stress. the urethral inclination angle and the posterior urethrovesical angle also became smaller at rest and on straining. A significant negative correlation was found between the postoperative mobility of the bladder neck and the post-operative pressure transmission ratio (PTR), indicating that correction of the urethrovesical anatomical disorder eliminates the functional disorder in this disease and restores continence.     

Bandelettes sous-urétrales et incontinence urinaire d’effort

The rational of the surgical treatment of female stress urinary incontinence has changed over the past few years. The techniques of colposuspension have been replaced by the suburethral slings, retropubic initially with the TVT, recreating a backboard between the urethra and the vaginal anterior wall. Nevertheless with overall cure rates of 69% to 88%, in periods beyond 5 years, the colposuspension still remains the reference (high-grade scientific evidence). Based on observational studies (low quality scientific evidence), with generally a short follow-up, the results of the TVT appear similar. More recently, the suburethral transobturator tape (TOT) was introduced to reduce the complications of the TVT. It is thus difficult to currently have an objective idea of the effectiveness of the TOT compared to the TVT, even if the first impressions, with respect to the TOT, are rather favourable. Furthermore the TOT technique itself and the biomaterials used, have continued to evolve. In fact, if the complications of these two kinds of suburethral slings are different: bladder perforation for the TVT, prosthetic erosion for the TOT, in contrast, in the future, their indications could be different. Therefore the TVT appears more effective in presence of intrinsic sphincter deficiency with urethral hypermobility.     

The ESGE Junior Platform

Our aim was to assess the safety and efficacy of the transobturator tape (TOT) for the surgical treatment of female stress urinary incontinence. We report our initial experience in a district general hospital and study the learning curve effect. This is a retrospective study of the first 125 women to have the TOT procedure (Aris® Transobturator Tape). Short-term follow-up took place with the operating gynecologist in the clinic 3 months postoperatively, while medium-term follow-up was assessed by a patient questionnaire at 18–36 months (mean 23 months). Short-term success rate was 89.3%. Complications were bladder injury 2.4%, postoperative urinary tract infection 8.1%, transient voiding dysfunction 13.7%, tape erosion 4.1%, and de novo urgency 14%. Questionnaire response rate was 66%. Subjective cure at 18–36 months was 81.5% with 88.9% reporting an improvement in quality of life. Ten women underwent repeat TOT after primary procedure failure with 80% success. Tape erosion occurred up to 17 months postoperatively, thus overall incidence was 6.4%. The incidence of bladder injury, tape erosion, and tape failure was higher in the first 60 patients, thus we performed an analysis of these events by the number of procedures performed and demonstrated a definite learning curve. The TOT is a safe and effective surgical treatment for stress urinary incontinence; however, as for all new surgical procedures, there exists a learning curve.     

Efficacy and Safety of Tension-Free Vaginal Tape Compared With Transobturator Tape Among Obese Women With Stress Urinary Incontinence: A Retrospective Cohort Study

ObjectiveTo determine the efficacy and safety of tension-free vaginal tape (TVT) compared with transobturator tape (TOT) in obese women with stress urinary incontinence (SUI).MethodsWe performed a retrospective chart review of patients who underwent insertion of TVT or TOT for stress urinary incontinence between January 2003 and October 2009. Women were excluded if they had had previous surgery for SUI or had a diagnosis of intrinsic sphincter deficiency.ResultsOne hundred eighty obese women (BMI >30 kg/m2) with SUI and with follow-up for at least one year were identified (90 had TVT and 90 had TOT). The rates of success on the objective criteria were 91% for the TVT group and 88% for the TOT group (P = 0.46) and 87% versus 80% (P = 0.23) on subjective assessment.ConclusionOur retrospective cohort study demonstrated similar rates of cure for obese women with SUI who underwent insertion of TVT and TOT.     

Impact of incontinence surgery on sexual function: a systematic review and meta-analysis

IntroductionUrinary incontinence has an adverse impact on sexual function. The reports on sexual function following the treatment of urinary incontinence are confusing.AimTo investigate the impact of surgery for stress incontinence on coital incontinence and overall sexual function.MethodsCochrane Incontinence Group Specialized Register of Controlled Trials, The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE were searched for trials of incontinence surgery assessing sexual function and coital incontinence before and after surgery. Observational studies and randomized controlled trials investigating the impact of surgical correction of stress urinary incontinence on sexual function were included. Surgical interventions included tension‐free vaginal tape (TVT), Tension Free Vaginal Tape‐Obturator (TVT‐O), transobturator tape (TOT), Burch, and autologous fascial sling (AFS). Studies that included patients undergoing concurrent prolapse surgery were excluded from the analysis. Data extraction and analysis was performed independently by two authors. Coital incontinence was analyzed separately and odds ratios (ORs) with 95% confidence intervals (CI) calculated. The data were analyzed in Review Manager 5 software.Main Outcome MeasureChanges in sexual function and coital incontinence following surgery for urinary incontinence.ResultsTwenty‐one articles were identified, which assessed sexual function and/or coital incontinence following continence surgery in the absence of prolapse. Results suggest evidence for a significant reduction in coital incontinence post surgery (OR 0.11; 95% CI 0.07, 0.17).ConclusionsCoital incontinence is significantly reduced following continence surgery. There were several methodological problems with the quality of the primary research particularly related to heterogeneity of studies, use of different outcome measures, and the absence of well‐designed randomized controlled trials. Jha S, Ammenbal M, and Metwally M. Impact of incontinence surgery on sexual function: A systematic review and meta‐analysis. J Sex Med 2012;9:34–43.     

A short-term follow-up comparison of two trans-obturator tape procedures

The objective of the study was to compare the clinical outcomes at the short-term follow-ups of two novel transobturator mid-urethral sling procedures – the transobturator tape (TOT) procedure and the tension-free vaginal tape (TVT)-obturator procedure. The study cohort consisted two groups of 40 women with urodynamically proven stress urinary incontinence (SUI). The patients in one group underwent the TOT procedure, performed according to Delorme (Prog Urol 11:1306–1313, 2001); those in the second group underwent the TVT-obturator operation, performed according to de Leval (Eur Urol 44:724–730, 2003). Intra-operative diagnostic cystoscopy was not performed with either the TVT-obturator or the TOT procedures. The average follow-up was 12 months. The two patient groups were similar in terms of demographic and therapeutic criteria, except for patient age, which was significantly younger in the TVT-obturator group. Previously reported TVT-related operative complications, such as bladder penetration, intra-operative bleeding, field infection and post-operative pelvic floor relaxation, were not observed in patients of either group. Bowel and urethral injuries were also not recorded. The therapeutic failure rates were 10% for the TOT procedure and 5% for the TVT-obturator procedure. Urinary frequency and urgency post-operatively were reported in 25% of the TOT patients and 19% of the TVT-obturator patients, pelvic or vaginal pain affected 10% of the TOT and 5% of the TVT-obturator patients, while post-operative voiding difficulty was experienced by 12.5% of the TOT and 7.5% of the TVT-obturator patients. None of the above-mentioned differences between the two patient groups were of statistical significance. The TVT-obturator and TOT procedures, both minimally invasive, novel, mid-urethral sling procedures, seem to be safe, easy-to-perform and effective in treating female SUI. The patients of both study groups suffered less intra- and post-operative surgical complications than previously been reported in connection with the TVT operation. The TVT-obturator patients had fewer therapeutic failures, less post-operative urinary frequency and urgency, less pelvic pain and less voiding difficulty. All of these findings, however, had no statistical significance; consequently, long-term comparative data collection will be required before solid conclusions can be drawn on the superiority of either of these two operative techniques.     

Successful Third Consecutive TVT in a Patient With Two Previous TVT Failures

BackgroundDuring 10 years of use, the transvaginal tape (TVT) technique has proved highly effective for the treatment of stress urinary incontinence. There is limited published information about experience with repeated TVT placementsCaseA 47-year-old multiparous woman presented with a history of two previous TVT sling procedures but persistent urinary incontinence. Persisting urinary incontinence was noted at six months after the first placement, and a second TVT placement was also unsuccessful. The preoperative urodynamic assessment showed type II and III urinary incontinence. The uterus was enlarged to the size of a 16-week pregnancy, and a hysterectomy was performed. At the same time, a third TVT sling procedure was performed using the standard free tension sling technique, leaving the arms uncut for 24 hours. The patient has remained continent during ten months of follow-up.ConclusionAccording to our experience with this patient, the placement of a third TVT after two failures is safe and effective.     

Minimally invasive techniques for female stress urinary incontinence, how, why, when

Aim

The main purpose of this paper is to summarize the recent experience that has been obtained till now in the surgical treatment of urinary stress incontinence with less invasive techniques.

Materials and methods

We used current literature and papers published in MEDLINE and Cochrane library. The keywords used for this review were Stress urinary incontinence, Tension-free vaginal tape (TVT), Transobturator tape (TOT, TVT-O), and Single-incision mini-slings (SIMS).

Results

Tension-free vaginal tape and the transobturator urethral suspension are the most commonly used surgical approach for women who suffer from stress urinary incontinence, with long-term success rates ranging from 84 to 95 %. TVT is shown to be as effective as the older colposuspension, associated with less post-operative complications, shorter hospital stay and shorter recovery period. Bladder perforations that have been mentioned with the TVT inserter apparently do not result in any clinically significant morbidity. Major vascular and bowel injuries have been reported at rates of 0.07 and 0.04 %, respectively. Studies between TVT-O and TOT show equal effectiveness with slightly lower cure rates than TVT group, but TOT had a significant lower risk of bladder and vaginal perforations. There were no significant differences in objective cure rates between ‘inside-out’ and ‘outside-in’ transobturator tapes. Very recently a meta-analysis does not support routine use of SIMS in clinical practice, moreover suggested the retropubic TVT as the preferred choice for the management of stress urinary incontinence due to familiarity, its effectiveness, minimal invasiveness and low complication and morbidity rates as a primary procedure. Similar results have been announced in a randomized control trial in USA.

Conclusions

Certainly, larger randomized clinical trials with longer follow-up about the mentioned techniques are needed to accurately determine the efficacy and safety of the mentioned minimally invasive techniques.