MRI visualization of the female pelvis in the plane of the tension-free vaginal tape (TVT) procedure

We evaluated the distances and angles of the major blood vessels from various pelvic structures in the plane of the tension-free vaginal tape (TVT) procedure in 19 pelvic MR imagies. The major blood vessels were the iliofemoral vessels. The mean distance of the left iliofemoral vessels from the midline was 5.7±0.4 cm, and 5.7±0.3 cm for the right vessels. The mean distance of the left sacral tuberosities from the midline was 5.5±0.4 cm, and 5.6±0.3 cm for the right vessels. The angle between the midurethra and the left iliofemoral vessels was 50.6±4.4 cm, and 49.6±4.0 cm for the right. A significant correlation was found between the distance of the right and left iliofemoral vessels from the midline and the distance of right and left sacral tuberosities from the midline (P<0.01, P<0.007). We suggest that palpation of the sacral tuberosities might indicate the location of the iliofemoral blood vessels.Abbreviations - TVT Tension-free vaginal tape - - MRI Magnetic resonance imagingEditorial Comment: The authors evaluated the distances and angles of the major pelvic blood vessels in the plane of the tension-free vaginal tape (TVT) procedure in 19 pelvic MR images. A statistically significant correlation was found between the distance of the iliofemoral vessels from the midline and the distance of the sacral tuberosities from the midline. The authors suggest that palpation of the sacral tuberosities might alert the surgeon to those patients at greater risk for iliofemoral vessel injury during the TVT procedure.The main concern with this study is that the pelvic MR images were obtained in the supine position whereas the TVT is performed in the lithotomy position, which may change the relations of pelvic blood vessels with reference to the urethra. Further studies are needed to evaluate the clinical significance of this interesting observation in reducing vascular injuries during the TVT procedure.     

Complication rates of tension-free midurethral slings in the treatment of female stress urinary incontinence: a systematic review and meta-analysis of randomized controlled trials comparing tension-free midurethral tapes to other surgical procedures and different devices

OBJECTIVES: To evaluate the complication rates of tension-free midurethral slings compared with other surgical treatments for stress urinary incontinence, including other tension-free midurethral slings. METHODS: A systematic review of the literature using MEDLINE, EMBASE, and Web of Science was performed in January 2007. Meta-analysis was conducted by using the Review Manager software 4.2. RESULTS: Our search identified 33 randomized controlled trials reporting data on complication rates. Our meta-analysis showed that complication rates were similar after tension-free vaginal tape (TVT) and Burch colposuspension, with the exclusion of bladder perforation, which was more common after TVT (p=0.0001), and reoperation rate, which was significantly higher after Burch colposuspension (p=0.02). TVT and pubovaginal sling were followed by similar complication rates. With regards to the comparisons among retropubic tapes, TVT and intravaginal slingplasty had similar complication rates, whereas suprapubic arc sling (SPARC) was complicated by higher rates of voiding lower urinary tract symptoms (LUTS) (p=0.02) and reoperations (p=0.04). Comparing retropubic and transobturator tapes, the occurrence of bladder perforations (p=0.007), pelvic haematoma (p=0.03), and storage LUTS (p=0.01) was significantly less common in patients treated by transobturator tapes. CONCLUSIONS: Tension-free slings were followed by lower risk of reoperation compared with Burch colposuspension, whereas pubovaginal sling and tension-free midurethral slings had similar complication rates. With regards to different tension-free tapes, voiding LUTS and reoperations were more common after SPARC, whereas bladder perforations, pelvic haematoma, and storage LUTS were less common after transobturator tapes. The quality of many evaluated studies was limited.     

Obturator nerve injury: a rare complication of retropubic tension-free vaginal sling

The tension-free vaginal tape (TVT) retropubic sling is a very effective treatment for stress urinary incontinence. High cure rates are typically achieved, and the reported complication rate is relatively low. Obturator neuralgia secondary to insertion of a midurethral sling is a rare and specific type of chronic pain that is more commonly associated with transobturator tape slings. The purpose of this video case report was to demonstrate that obturator nerve injury is a possible complication of TVT retropubic slings placement. A discussion of symptoms and signs of obturator nerve injury and how these should be managed is also presented.     

Does Body Mass Index Impact Passing Voiding Trial After Midurethral Sling Procedures for Stress Urinary Incontinence?

OBJECTIVE:: To test the hypothesis that body mass index (BMI) is a factor associated with passing a voiding trial after midurethral sling procedures for stress urinary incontinence (SUI). STUDY DESIGN:: The medical records of 136 consecutive patients who underwent placement of either tension-free vaginal tape (TVT) or transobturator tape (TOT) for SUI during a 1-year period (September 1, 2007 to August 31, 2008) were retrospectively reviewed. Variables assessed were BMI, age, and passing or failing a postoperative urinary voiding trial. Patients with concomitant pelvic organ prolapse surgeries were not included in this analysis. RESULTS:: Sixty-seven patients underwent TVT, whereas 69 had TOT procedures. In the TVT group, 30 patients (42%) were unable to void immediately postoperatively compared with 11 patients (16%) in the TOT group (P = 0.0003). The mean (SD) age and BMI of patients who failed or passed voiding trials was 58.6 (12.0) years and 28.0 (4.9) kg/m or 53.5 (12.3) years and 29.8 (5.7) kg/m, respectively. Of 38 patients who did not pass a voiding trial on the day of the procedure, 31 (82%) passed on postoperative day 1, and all patients had passed a voiding trial by postoperative day 11. The mean (SD) BMI for 7 patients who did not pass voiding trial by postoperative day 1 was 28.3 (5.2) kg/m. CONCLUSIONS:: Women with higher BMIs were more likely to pass voiding trials after midurethral sling procedures. Patients who had TOT placement had greater success passing a postprocedure voiding trial than did patients who had TVT placement.     

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.     

Complication Rates of Tension-Free Midurethral Slings in the Treatment of Female Stress Urinary Incontinence: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Comparing Tension-Free Midurethral Tapes to Other Surgical Procedures and Different Devices

Objectives

To evaluate the complication rates of tension-free midurethral slings compared with other surgical treatments for stress urinary incontinence, including other tension-free midurethral slings.

Methods

A systematic review of the literature using MEDLINE, EMBASE, and Web of Science was performed in January 2007. Meta-analysis was conducted by using the Review Manager software 4.2.

Results

Our search identified 33 randomized controlled trials reporting data on complication rates. Our meta-analysis showed that complication rates were similar after tension-free vaginal tape (TVT) and Burch colposuspension, with the exclusion of bladder perforation, which was more common after TVT (p = 0.0001), and reoperation rate, which was significantly higher after Burch colposuspension (p = 0.02). TVT and pubovaginal sling were followed by similar complication rates. With regards to the comparisons among retropubic tapes, TVT and intravaginal slingplasty had similar complication rates, whereas suprapubic arc sling (SPARC) was complicated by higher rates of voiding lower urinary tract symptoms (LUTS) (p = 0.02) and reoperations (p = 0.04). Comparing retropubic and transobturator tapes, the occurrence of bladder perforations (p = 0.007), pelvic haematoma (p = 0.03), and storage LUTS (p = 0.01) was significantly less common in patients treated by transobturator tapes.

Conclusions

Tension-free slings were followed by lower risk of reoperation compared with Burch colposuspension, whereas pubovaginal sling and tension-free midurethral slings had similar complication rates. With regards to different tension-free tapes, voiding LUTS and reoperations were more common after SPARC, whereas bladder perforations, pelvic haematoma, and storage LUTS were less common after transobturator tapes. The quality of many evaluated studies was limited.     

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.     

Transobturator tape,bladder perforation,and paravaginal defect: a case report

Transobturator midurethral slings (TOT) have been shown to have less risk of vascular and visceral injury than tension-free midurethral slings. Routine cystoscopy has therefore not been felt to be necessary. A case of bladder perforation unrecognized at the time of TOT placement is presented. Findings at sling removal suggested that a clinically nonapparent paravaginal defect may have been instrumental in the injury. Consideration should be given to routine cystoscopy at the time of transobturator sling placement.     

TVT and Sparc suburethral slings: a case-control series.

Two midurethral slings, TVT and Sparc, are the subject of this case-control series aimed at assessing sling placement, voiding function, bladder symptoms and patient satisfaction. Thirty-seven Sparc and 69 TVT patients were matched for age, body weight, pre-existing urge incontinence, preoperative voiding, concomitant surgery and length of follow-up (mean 0.6, range 0.1-1.5 years). There were no significant differences for subjective cure/improvement, satisfaction or symptoms of incontinence. The clinical stress test was positive in 8/37 Sparc vs 4/69 TVT patients ( p=0.019). The TVT had a more negative effect ( p=0.001) on postoperative voiding. The Sparc was situated more cranially at rest and further from the symphysis pubis, and was more mobile ( p<0.001) on Valsalva. There are significant differences in medium-term outcomes after TVT and Sparc, affecting tape placement, mobility, effect on voiding function and objective stress continence. Patient satisfaction and subjective cure rates seem similar.     

Evaluation of the local carcinogenic potential of mesh used in the treatment of female stress urinary incontinence

Introduction and hypothesis

To evaluate the carcinogenic potential of implanted synthetic mesh midurethral slings in the treatment of female stress urinary incontinence.

Methods

We identified female patients undergoing implantation of mesh materials for stress urinary incontinence at our institution from 1 January 2002 to 31 December 2012. This was accomplished by querying the medical records for CPT code 57288 (“sling operation for stress incontinence”) and a subsequent chart review to identify patients who underwent synthetic mesh sling placement. Medical records were then evaluated for the documentation of bladder, urethral, vaginal, cervical, uterine or ovarian cancers via the International Classification of Disease (ninth edition) coding. A chart review of patients with a cancer diagnosis was performed for verification of the diagnosis and evaluation of the temporal relationship with sling placement.

Results

During the study period, 2,474 patients underwent polypropylene midurethral sling placement. The median age was 57 years (IQR 47, 69) and the median follow-up was 60 months (IQR 23.3, 94.9). Overall, 51 patients also had a cancer diagnosis (8 bladder cancers, 7 vaginal malignancies, 8 ovarian carcinomas, 26 endometrial cancers, 2 cervical malignancies); however, only 2 cancers (0.08 %, 2 out of 2,474) developed following sling placement (a vaginal melanoma 3 years after sling placement and an ovarian tumor 1 year after sling placement). No cases of sarcoma formation, bladder, urethral or squamous cell carcinomas were identified.

Conclusions

With a median follow-up of 5 years after synthetic midurethral sling placement, development of pelvic malignancy was rare (0.08 %) and unlikely to be secondary to foreign body reaction from the implanted material.

     

Anatomy of the obturator region: relations to a trans-obturator sling

Our objective was to determine the relationships between a trans-obturator sling and anatomic structures within the obturator region. The obturator regions of six cadavers were dissected and distances from the mid-point of the ischiopubic ramus to the muscles, nerves, and vessels of the region were measured. A trans-obturator sling was placed and distances from the device to the same anatomic structures were determined. Four additional cadavers were dissected to determine the device route of passage. The obturator canal is on average 4.4 cm from the midpoint of the ischiopubic rami. The trans-obturator sling passes on average 2.4 cm inferior-medial to the obturator canal. The anterior and posterior divisions of the obturator nerve are on average 3.4 and 2.8 cm, respectively, from a passed trans-obturator device. The device passed on average 1.1 cm from the most medial branch of the obturator vessels. Vascular and nerve structures are within 1–3 cm of the path of any device passed through the obturator foramen. A trans-obturator sling risks injury to these structures, although the small caliber of the vessels and the confined space in which they would bleed make the consequences of injury uncertain.Editorial Comment: The authors performed anatomic dissections in fresh frozen cadavers to better understand the anatomy faced during the performance of a transobturator sling procedure. Since this anatomy has not been critically analyzed by the vast majority of pelvic surgeons, it is important for the practicing pelvic surgeon to attain a very clear image of the vascular and neurologic relationships in this area. The dissections were performed with the patients in high lithotomy position. Therefore, there is great clinical value to these dissections. However, the surgeon must also realize that a significant degree of variability exists, especially as related to vascular anatomy. This has implications for the safe performance of this novel approach to stress incontinence     

TVT and Sparc suburethral slings: a case–control series

Two midurethral slings, TVT and Sparc, are the subject of this case–control series aimed at assessing sling placement, voiding function, bladder symptoms and patient satisfaction. Thirty-seven Sparc and 69 TVT patients were matched for age, body weight, pre-existing urge incontinence, preoperative voiding, concomitant surgery and length of follow-up (mean 0.6, range 0.1–1.5 years). There were no significant differences for subjective cure/improvement, satisfaction or symptoms of incontinence. The clinical stress test was positive in 8/37 Sparc vs 4/69 TVT patients (p=0.019). The TVT had a more negative effect (p=0.001) on postoperative voiding. The Sparc was situated more cranially at rest and further from the symphysis pubis, and was more mobile (p<0.001) on Valsalva. There are significant differences in medium-term outcomes after TVT and Sparc, affecting tape placement, mobility, effect on voiding function and objective stress continence. Patient satisfaction and subjective cure rates seem similar.Abbreviations TVT Tension-free vaginal tapeEditorial Comment: The authors are to be commended for performing such timely research as clinicians struggle to understand the differences, if any, among the various minimally invasive midurethral slings that have been developed since the original tension-free tape (TVT) procedure. Despite the authors proposed explanation of a pretensioning effect, without intraoperative ultrasound measurements of tape displacement before and immediately after sheath removal, several other equally plausible explanations exist. It is also interesting to note the differences in postoperative voiding parameters and objective cure rates that once again remind us of the difficulty in surgically achieving high objective cure rates for stress incontinence without compromising normal outflow during micturition.     

Urodynamic changes after tension-free sling procedures: Mycromesh-Plus® vs TVT sling®

Assortments of suburethral sling procedures have become increasingly important in the treatment of stress urinary incontinence (SUI). This study compared a consecutive series of patients undergoing two types of no-tension, midurethral sling procedures: a traditional pubovaginal technique and graft (modified polytetrafluoroethylene graft; Mycromesh-Plus® [MMP]) and the more recently introduced tension-free vaginal tape (TVT) sling. We observed for differences in success rates, urodynamic parameters, and complications of the two procedures. One group received a MMP sling, which was placed at the midurethra without tension. The other group underwent a minimally invasive TVT sling. Multichannel urodynamic studies were performed pre- and postoperatively. Cure rates for SUI were similar for the two groups (95 vs 95%). Urgency and urge incontinence symptoms improved substantially in both groups. Comparison of pre- and postoperative urodynamic indices demonstrated no differences in changes in average functional urethral lengths, changes in maximum urethral closure pressures, or improvement in pressure transmission ratios. Both groups showed a decrease in urethral mobility postoperatively. However, the TVT group demonstrated a lesser degree of change. While the TVT group did spontaneously void earlier than the MMP group (5.7 vs 9.7 days, p?相似文献   

Which placement of the tension-free vaginal tape is more important for urinary continence: midurethral position or bladder neck? Consideration from a case report

The tension-free vaginal tape (TVT) is a well-established surgical procedure for the treatment of female urinary stress incontinence. Midurethral position was thought not to be necessary to achieve continence. But in our study, a patient with stress urinary incontinence was treated with a TVT suburethral sling. The symptoms of stress urinary incontinence still exist after the TVT procedure. With physical treatment and anti-inflammatory treatment, no relief was found. At the 50-day follow-up, the symptoms of stress incontinence worsened. Transperineal three-dimensional ultrasound revealed that the sling migrated from the midurethra to the bladder neck. With adjustment of the sling, the symptom of stress incontinence was improved and no complication was observed at the 6- and 12-month follow-up. Sling migration should be considered in a patient who presents with recurrent stress incontinence at the earlier postoperative period. We think that the midurethral position is necessary to achieve continence.     

Detrusor overactivity and urge urinary incontinence following trans obturator versus midurethral slings

AIMS: To compare the rates of resolution of detrusor overactivity (DO) and subjective urge urinary incontinence (UUI) as well as de novo DO and UUI between the Monarc, TVT, and SPARC midurethral sling procedures. METHODS: Two hundred and seventy-six subjects with urodynamic stress or mixed urinary incontinence underwent retropubic midurethral slings (TVT, N = 99; SPARC, N = 52) or transobturator slings (Monarc, N = 125). All evaluable subjects had a routine office evaluation, subjective assessment of UUI, and multichannel urodynamic testing pre- and 3 months postoperatively. Comparisons were made using Student's t-test, ANOVA, McNemar's test, and Chi-Square test where appropriate. Multivariate logistic regression was performed to detect possible confounding factors such as sling type, and differences in concomitant surgical procedures. RESULTS: De novo subjective UUI differed significantly between the Monarc and the other two slings (33% TVT vs. 8% Monarc vs. 17% SPARC, P = 0.04). Fourteen to Sixteen percents of patients with preoperative UUI who underwent TVT or SPARC had worsening of their UUI symptoms while only 6% of the Monarc group did (P = 0.02). There was no difference in rates of resolution of DO among the three groups (40% vs. 48% vs. 32%, P = 0.39) or de novo DO (32% vs. 22% vs. 22%, P = 0.64) at 3 months. CONCLUSIONS: Patients who undergo transobturator procedures have significantly lower rates of de novo UUI than those who undergo midurethral sling procedures. Rates of resolution of DO, UUI, and de novo DO do not differ between groups.     

Bladder wall abscess following midurethral sling procedure

Midurethal sling procedures are gaining popularity as the treatment of choice for stress urinary incontinence. Complications that were described include bladder perforation, urinary retention, pelvic hematoma and suprapubic wound infection. Sling erosion and pelvic abscess are rare complications of midurethral slings. We report the first case of an abscess formed within the wall of the urinary bladder, 7 months following a midurethral sling procedure.     

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.     

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.