The Role of Intrinsic Sphincteric Deficiency Diagnosis in the Era of Midurethral Sling

The midurethral sling has gained popularity and is the most commonly used treatment of women with stress urinary incontinence (SUI). Whether intrinsic sphincteric deficiency (ISD) still should be used in the preoperative evaluation of patients with SUI and whether it should be considered as a predictor of success in patients undergoing a midurethral sling procedure and as a guide in the choice of surgical approach (retropubic vs transobturator) remain controversial. This article reviews and discusses the definitions of ISD and the latest research into the role of ISD determination in the era of the midurethral sling.     

Health-related quality of life. The effect of pelvic floor muscle training and midurethral sling surgery: a systematic review

Stress urinary incontinence (SUI) is a bothersome condition affecting health-related quality of life (HRQoL) to a great extent in women. From a patient's perspective, improving HRQoL is probably equally important as objective cure of SUI. Our objective was to assess the effect of pelvic floor muscle training (PFMT) and midurethral sling surgery on condition-specific HRQoL in women with SUI. A systematic literature search was conducted in the PubMed, Embase, and Cochrane databases. Studies reporting on HRQoL after intervention for SUI or mixed incontinence with a predominant SUI component were selected. Retrieved articles were appraised by all authors regarding participant entry criteria, study design, intervention, questionnaire, objective cure, and HRQoL presentation. There were three articles reporting HRQoL after PFMT and 11 after midurethral sling surgery. Improvement in HRQoL seemed higher after midurethral sling surgery compared with PFMT. However, methods of HRQoL assessment varied widely, limiting the possibility of comparison and interpretation between studies.     

Sexual function following outside-in transobturator midurethral sling procedures: a prospective study

Introduction and hypothesis

Midurethral tapes have shown favorable clinical outcomes for treating stress urinary incontinence (SUI), but the effects of outside-in transobturator midurethral sling procedures (TOT) on women??s sexual function are unclear. We hypothesized that TOT might improve sexual function in women with SUI and therefore conducted this study to investigate sexual function alteration among women who underwent TOT for urodynamic stress incontinence (USI).

Methods

From November 2009 to October 2010, we recruited 102 women scheduled for correction of USI by TOT procedures in a tertiary hospital. In addition to urogynecologic history, pelvic examination, and urodynamic testing, participants were required to complete three validated questionnaires: Incontinence Impact Questionnaire (IIQ-7), Urogenital Distress Inventory (UDI-6), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Preoperative and postoperative results of these validated questionnaires were evaluated.

Results

Eighty-three patients comprising 57 sexually active and 26 sexually inactive patients participated in the 12-month evaluation. Of the 83 patients undergoing TOT, six (7.2?%) had postoperative SUI 12?months postoperatively. Both UDI-6 and IIQ-7 scores were significantly improved postoperatively. The total PISQ-12 score did not change significantly after surgery. Postoperatively, the individual incontinence-related items of the PISQ-12 improved, but climax with intercourse and negative emotional reactions during intercourse worsened (both with p <0.001). There was a negative correlation between SUI-related items on UDI-6 and those on PISQ-12 preoperatively.

Conclusions

TOT procedures for correcting USI had favorable clinical outcomes and did not alter overall sexual function; however, climax during sexual intercourse and emotional response worsened postoperatively.     

Health-related quality of life and sexual function in women with stress urinary incontinence and overactive bladder

Background:   We evaluated the impact of stress urinary incontinence (SUI) and overactive bladder (OAB) on health-related quality of life (HRQOL) and sexual function.
Methods:   A total of 245 women (SUI; n  = 123 and OAB; n  = 122) from 21 to 79 years old (mean 50.4) were included in the primary analyses. To obtain HRQOL and sexual function assessments, patients were asked to fill in the 'Bristol Female Lower Urinary Tract Symptoms (BFLUTS)' and the 'Medical Outcomes Study Short Form (SF-36)' questionnaires.
Results:   Of the eight domains in the SF-36 questionnaire, only 'general health' was significantly different between the groups. Patients with SUI had a better general health than those with OAB ( P  = 0.016). When comparing the BFLUTS scores in the two groups, the score for 'BFLUTS-filling symptoms' was higher in the OAB group ( P  = 0.002) but that for 'BFLUTS-incontinence symptoms' was higher in the SUI group ( P  < 0.001). The score for 'BFLUTS-sex' was higher in the SUI group than in the OAB group but this was not statistically significant ( P  = 0.096). Of the 169 patients who had a sex life, the SUI group had experienced pain ( P  = 0.033) and leakage ( P  = 0.056) more frequently during intercourse than the OAB group.
Conclusion:   Both SUI and OAB have a detrimental impact on patient HRQOL in Korean women. In addition, our findings suggest that women with SUI had more frequently experienced pain during intercourse and coital incontinence than those with OAB.     

Indications and risk factors for midurethral sling revision

Introduction and hypothesis

To determine the indications and risk factors for needing midurethral sling revision in a cohort of women undergoing midurethral sling placement.

Methods

This was a case–control study of all women undergoing midurethral sling placement for stress urinary incontinence (SUI) between January 2003 and December 2013. Cases were patients who underwent midurethral sling placement followed by sling revision (incision, partial or complete excision). Controls were patients who underwent sling placement only. Once all subjects had been identified, the electronic medical record was queried for demographic and perioperative and postoperative data.

Results

Of 3,307 women who underwent sling placement, 89 (2.7 %, 95 % CI 1.9 – 3.4) underwent sling revision for one or more of the following indications: urinary retention (43.8 %), voiding dysfunction (42.7 %), recurrent urinary tract infection (20.2 %), mesh erosion (21.3 %), vaginal pain/dyspareunia (7.9 %), and groin pain (3.4 %). The median time from the index to the revision surgery was 7.8 months (2.3 – 17.9 months), but was significantly shorter in patients with urinary retention. The type of sling placed (retropubic or transobturator) was not associated with indication for revision. Patients who underwent revision surgery were more likely to have had previous SUI surgery (adjusted odds ratio 4.4, 95 % CI 1.7 – 6.5) and to have undergone concomitant vaginal apical suspension (adjusted odds ratio 2.4, 95 % CI 1.4 – 4.5).

Conclusions

The rate of sling revision after midurethral sling placement was 2.7 %. Urinary retention and voiding dysfunction were the most common indications. Patients with a history of previous SUI surgery and concomitant apical suspension at the time of sling placement may be at higher risk of requiring revision surgery.

     

TVT versus SPARC: comparison of outcomes for two midurethral tape procedures

To compare the subjective and objective cure rates in women who underwent either the SPARC or the TVT midurethral sling for the treatment of stress urinary incontinence. This retrospective study included all 122 consecutive women undergoing a TVT or SPARC midurethral sling procedure for objective stress urinary incontinence between January 2000 and March 2003 at the Evanston Continence Center. Primary outcomes were subjective and objective stress incontinence cure rates. Subjects underwent multichannel urodynamics preoperatively and 14 weeks postoperatively, and stress testing at last follow-up. The two groups were compared using univariate and multivariate analyses. Seventy-three subjects underwent a TVT and 49 subjects had a SPARC procedure. There were no statistical differences in demographic factors between the two groups. Subjects undergoing SPARC were more likely to void by Valsalva effort. One hundred and seven women returned for objective postoperative evaluation after surgery. The TVT procedure was associated with higher subjective (86 vs. 60%, P=0.001) and objective (95 vs. 70%, P<0.001) stress incontinence cure rates. There was no difference between the TVT and SPARC groups in the resolution of subjective and objective urge urinary incontinence. TVT was associated with a higher stress urinary incontinence cure rate than SPARC in this retrospective study. As new midurethral sling products are introduced, prospective randomized controlled trials should be conducted to evaluate their relative efficacy and safety.     

Pelvic floor muscle training improves sexual function of women with stress urinary incontinence

The aim of this study was to assess the effect of a program of supervised pelvic floor muscle training (PFMT) on sexual function, in a group of women with urodynamically diagnosed stress urinary incontinence (SUI), using a validated questionnaire. Incontinence episodes frequency and continence pads used per week were measured before and after treatment using a 7-day bladder diary. Improvements in sexual function were assessed using the Female Sexual Function Index (FSFI). Seventy women completed the 12-month program of supervised PFMT successfully. At the end of the study, incontinence episode frequency decreased by 38.1%, and patients required 39% less pads per week. All domains of the FSFI were also significantly improved with median total FSFI scores increasing from 20.3 to 26.8. This is one of the few studies to quantify, using a validated questionnaire, the improvement in sexual function of women with SUI, undergoing successfully a 12-month supervised PFMT program.     

Analysis of early outcome: Burch procedure versus pubovaginal sling

The Burch vesicourethral suspension (BUVS) has long been the procedure of choice for female stress urinary incontinence (SUI) because of its low complication rate and high success rate for all but those patients with type 3 SUI. The pubovaginal sling (PVS) procedure yields a high success rate in those with type 3 SUI but has not gained wide use for all types of SUI, owing to initial reports of a higher complication rate. A retrospective review of early effectiveness and complications associated with BUVS performed on 36 women without type 3 SUI compared to that for PVS performed on 42 women (24 with and 18 without type 3 SUI) at our institution was carried out. To ensure reasonable comparability between groups, homogeneous subsets of 18 women undergoing BUVS and 18 women undergoing PVS were defined. Using conservative criteria for early complications. PVS patients experienced half the complications of BUVS patients with a comparable rate of success.Editorial Comment: The authors present short-term results of the Burch procedure performed for GSI with documented urethrovesical junction hypermobility compared to the results of the suburethral sling performed for any type of GSI, regardless of urethral function or bladder neck support. The real decision on surgical procedure is clearly stated to be which surgical department performed the operation. There are therefore more than two different patient populations undergoing different procedures by different surgeons. The short-term results presented by the authors indicate that the sling procedure, although more costly, has fewer complications than the Burch procedure, with equivalent success rates even when applied to patients with varying degrees of GSI. Other centers have consistently over time reported higher incidences of postoperative complications, including postoperative voiding dysfunction, detrusor instability, urinary tract infection and wound healing problems (when using foreign sling material), in association with the sling procedure. Added to the short follow-up time, the lack of objective postoperative evaluation and poor assessment of subjective patient response and change in quality of life, it is premature to conclude that the sling procedure should be performed on all patients with stress loss of urine with no preoperative urodynamic testing.     

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.     

Redo midurethral synthetic sling for female stress urinary incontinence

Tension-free transvaginal tape (TVT) placement has recently become the preferred therapeutic approach for female stress urinary incontinence (SUI) in some centers. There are, however, no clearcut guidelines of how to treat patients in whom the procedure has failed. We describe our experience with repeat midurethral synthetic sling (MUS) implantation after a failed similar procedure. Twelve women (mean age 64.3 years) who had undergone a MUS procedure [TVT—9, intravaginal sling (IVS)—2, transobturator tape (TOT)—1] for SUI underwent a repeat MUS (TVT—5, IVS—4, TOT—3) due to persistent or recurrent SUI. The time from the first to the second procedure was 1–48 months. Eleven out of 12 patients (91.7%) achieved full continence (mean follow-up of 23.2 months, range 14–44). We conclude that a repeat MUS for persistent or recurrent SUI is a viable option for patients after an unsuccessful MUS procedure.     

Urethral slings placed by the transobturator approach: Evolution in the technique and review of the Literature

Midurethral slings have proven to be efficacious in the surgical treatment of stress urinary incontinence (SUI) in women. A relatively new approach to the midurethral sling technique is the transobturator route for placement of the sling. This approach offers the theoretical safety advantage of avoiding the retroperitoneal space. The procedure has been pioneered in Europe and is now being practiced in the United States. In this article, we describe the theory behind urethral slings for SUI, the anatomy of the obturator canal, and early data on the safety and efficacy of transobturator urethral slings in the treatment of SUI.     

经闭孔无张力尿道中段吊带术联合阴道前壁修补术治疗女性压力性尿失禁

目的 评价经闭孔无张力尿道中段吊带术(TVT-O)联合阴道前壁修补术治疗合并阴道前壁脱垂的女性压力性尿失禁(stress urinary incontinence,SUI)的效果.方法 行TVT-O联合阴道前壁修补术治疗合并阴道前壁脱垂的女性压力性尿失禁18例.术后随访12个月,进行主观治疗结果及术后远期并发症的调查.术后12个月时,复查盆腔器官脱垂定量分度法(POP-Q)分期、尿流率、性生活质量评分(PISQ-12).结果 尿失禁主观治愈率为88.9%(16/18),主观改善率为11.1%(2/18).4例阴道前壁脱垂复发(术前Ⅲ期3例,Ⅱ期1例,术后均为Ⅰ期),11名有规律性生活的患者PISQ-12评分术前术后分别为27.5±4.4和31.2±6.1(P＜0.05).结论 TVT-O联合阴道前壁修补术治疗合并中度阴道前壁脱垂的女性压力性尿失禁简便易行,疗效可靠,对患者性功能无不利影响.     

Management of recurrent stress urinary incontinence and urinary retention following midurethral sling insertion in women

INTRODUCTION

Synthetic midurethral slings are the most common operations performed for women with stress urinary incontinence (SUI). However, there is only very scarce evidence regarding the management of complications from these operations. The aim of this survey was to canvass expert opinion regarding the management of recurrent SUI and urinary retention following insertion of these slings.

METHODS

Expert urologists and urogynaecologists in the UK with an interest in SUI were identified. Three clinical scenarios on recurrent SUI and one on urinary retention following midurethral sling placements were emailed twice to the experts.

RESULTS

The majority of the experts chose a repeat synthetic midurethral retropubic transvaginal tape (TVT) as the procedure of choice for recurrent SUI in patients who had had a previous TVT or midurethral transobturator tape inserted. In patients who continued to suffer SUI after a failed second TVT, there were mixed results with experts choosing fascial slings, colposuspension and bulking agents as their preferred method of treatment. In women who develop urinary retention following a TVT, tape pull-down within two weeks was the preferred method among the experts. However, division of the tape within two to six weeks following the procedure was also popular.

CONCLUSIONS

Based on expert opinion, it is difficult to make a recommendation as to the best method of treating recurrent SUI or urinary retention following tape insertion. There is an urgent requirement for well conducted, multicentre, randomised clinical trials to look at the management of these complications and also the tools used to assess the patient before salvage surgical management.     

Effect of detrusor function on the therapeutic outcome of a suburethral sling procedure using a polypropylene sling for stress urinary incontinence in women

OBJECTIVE: To assess the effect of detrusor function on the therapeutic outcome of a suburethral sling procedure in women with stress urinary incontinence (SUI). MATERIAL AND METHODS: A total of 192 women with SUI who had undergone a suburethral sling procedure were enrolled. According to the baseline urodynamic results, patients' bladder functions were classified as follows: (i) normal detrusor function; (ii) detrusor overactivity; and (iii) detrusor underactivity or acontractile detrusor. Surgical results, urodynamic parameters and patient satisfaction were compared among these three groups. RESULTS: Overall, 106 patients had normal detrusor function, 36 had detrusor overactivity and 50 had detrusor underactivity or an acontractile detrusor. A continent outcome was achieved in 135 women (70.3%), urge incontinence in 23 (12%), minimal SUI in 32 (16.7%) and moderate SUI in two (1%). Persistent urge incontinence was noted in 13 women (36%) with detrusor overactivity, and recurrent SUI occurred in 18 women (36%) with detrusor underactivity or an acontractile detrusor. No significant change in urodynamic parameters between baseline and after treatment was found in any of the patient groups. The satisfaction rate was 98.1% in patients with normal detrusor function, 82% in patients with detrusor underactivity or an acontractile detrusor and 75% in patients with detrusor overactivity (p<0.05). CONCLUSION: Compared to women with normal detrusor function, those with preoperative detrusor overactivity and those with detrusor underactivity or an acontractile detrusor experienced an unfavorable therapeutic outcome of the suburethral sling procedure in terms of urge incontinence and recurrent SUI after surgery.     

The surgical results of the pubovaginal sling procedure using polypropylene mesh for stress urinary incontinence

OBJECTIVE: To investigate the surgical results after a pubovaginal sling procedure using polypropylene mesh in women with stress urinary incontinence (SUI). PATIENTS AND METHODS: Sixty-four women with different types of SUI underwent a pubovaginal sling procedure, using polypropylene mesh. The sling was placed at the level of the proximal half of the urethra and tied with adequate tension, but not obstructing the bladder outlet. A video-urodynamic study and transrectal ultrasonography were undertaken before and after surgery. The surgical results were assessed and the urodynamic changes compared at different stages. RESULTS: At a median follow-up of 24 months, 52 patients (81%) were completely continent, 10 (16%) had an improvement but with mild SUI, and two had persistent SUI requiring a second sling procedure. The treatment result was considered satisfactory by 55 patients (86%). The video-urodynamic study showed no significant change in voiding pressure, cystometric capacity and residual urine volume after surgery. The bladder neck opening time was increased at 7 days and the maximum flow rate increased at 3 months after surgery. Transrectal ultrasonography showed that all the polypropylene mesh slings were located beneath the bladder neck and proximal urethra, with no notable granuloma formation around the sling. CONCLUSION: The pubovaginal sling procedure is effective in treating female SUI, using polypropylene mesh as the sling material. The video-urodynamic results showed that a pubovaginal sling of polypropylene mesh causes no bladder outlet obstruction when the correct surgical technique is used.     

Extraperitoneal laparoscopic removal of eroded midurethral sling: a new technique

PURPOSE: Erosion of a midurethral sling is common in women who are treated for stress urinary incontinence. This complication is usually managed by retropubic exploration. We report a novel technique to manage erosion in patients who refuse retropubic exploration. PATIENTS AND METHODS: Two women (ages 47 and 53 years) with stress urinary incontinence were treated with a midurethral sling. Postoperatively, at 24 and 22 months, respectively, the sling had eroded through the high urethra near the bladder neck. A three-port extraperitoneal laparoscopic approach was used to remove the urethral slings and repair the bladder. RESULTS: The procedure was accomplished in 80 and 75 minutes, respectively, with no complications. Both patients remained continent. CONCLUSION: A minimally invasive extraperitoneal surgical technique can be used to manage midurethral sling erosion in women.     

Midurethral sling shortening for persistent stress urinary incontinence

We describe techniques and objective and subjective outcomes for women who underwent midurethral sling (MUS) shortening for persistent stress urinary incontinence (SUI). This is a case series of women who underwent MUS shortening for SUI within 8 weeks of initial MUS placement. Objective and subjective findings including Urinary Distress Inventory (UDI)-6 and Urinary Impact Questionnaire (UIQ)-7 scores are reported, and shortening techniques are described. Between June 2007 and June 2010, three women underwent MUS shortening for persistent SUI within 8 weeks of initial MUS placement. Shortening was performed with either midline plication or mesh excision and reapproximation. Five months postoperative to shortening, one woman reported subjective improvement in SUI symptoms, and two had subjective and objective resolution of SUI. All showed improvement from baseline in UDI-6 and UIQ-7 scores. There were no erosions. MUS shortening may offer a safe and effective option for management of persistent SUI.     

Comparison of retropubic and outside-in transoburator sling systems for the cure of female genuine stress urinary incontinence

OBJECTIVES: Retropubic tension-free slings are a well established procedure in the treatment of SUI. There were and still are relevant complications and side effects. The transobturator approach is said to be safer and equally effective. This paper compares our data of the first TVT- and TOT-procedures to share our experience. METHODS: In this study (from May 1998 to November 1999 for TVT and from February 2003 to September 2003 for TOT) only patients (n=220 in each group) with genuine SUI due to urethral hypermobility and/or intrinsic sphincter deficiency not showing signs of vaginal prolapse were evaluated. The results of pre- and postoperatively conducted examinations, quality-of-life assessments and urodynamic studies are reported. RESULTS: TOT is equally effective with less intraoperative and postoperative complications (including induction of urge). The procedure is faster and does not necessarily need intraoperative cystoscopy (even though cystoscopy adds to the procedure's safety)--it is thereby cheaper. CONCLUSIONS: performed under the right indication the transobturator approach seems to be preferable when a low-tension midurethral sling procedure is the method of choice.     

Simple sling incision for the treatment of iatrogenic bladder outlet obstruction

Introduction and hypothesis

Bladder outlet obstruction (BOO) is reported to occur in 15 % of women after anti-incontinence surgery. In the past, iatrogenic BOO from slings was treated with urethrolysis. However, urethrolysis is not without morbidity, including significant bleeding, urethral injury, and recurrent stress urinary incontinence (SUI). Several studies have shown simple sling incision to be as effective as urethrolysis with less morbidity and lower rates of recurrent SUI. [1–3]

Methods

We demonstrate the technique of transvaginal simple sling incision in two patients, one with a synthetic midurethral sling, and one with a biologic bladder-neck sling.

Results

Simple sling incision is an effective and less morbid treatment than urethrolysis for iatrogenic urethral obstruction; 70–90 % of women will have significant improvement in obstructive voiding symptoms. Recurrent SUI is seen in approximately 20 % of women after sling incision.

Conclusions

This video shows that simple sling incision is an effective, simple, and safe treatment for women with iatrogenic BOO after sling surgery and should be used as a first-line treatment.     

Urinary retention is uncommon after colpocleisis with concomitant mid-urethral sling

The purpose of this study was to evaluate the effect of colpocleisis and concomitant mid-urethral sling on voiding function. This is an IRB-approved, retrospective case series of women who underwent a colpocleisis with concomitant synthetic mid-urethral sling for treatment of stress urinary incontinence (SUI) between January 2005 and September 2007. Thirty-eight women with pelvic organ prolapse and SUI symptoms were included. Thirty percent had a post-void residual (PVR) greater than 100 ml preoperatively. PVRs were normal in all but two women after surgery. Median prolapse and urinary subscales of the pelvic floor distress inventory improved significantly after surgery [75 (50–100) vs. 0 (0–38), p < 0.0001 and 44 (8–100) vs. 0 (0–50), p < .0001, respectively]. Colpocleisis with concomitant mid-urethral sling improves urinary symptoms without causing significant urinary retention. This combination may be offered to elderly women with SUI who are undergoing colpocleisis regardless of preoperative PVR.