Urethral bulking for recurrent stress urinary incontinence after midurethral sling failure

Aims

To assess the effectiveness of a polyacrylamide hydrogel (PAHG; Bulkamid®) in treating recurrent stress urinary incontinence (SUI) following a previous midurethral sling (MUS) implant.

Methods

This observational study, conducted since 2009, included 60 patients with recurrent SUI or mixed urinary incontinence (MUI) after a previous MUS and who chose to be treated with PAHG. Objective and subjective outcomes were assessed at 1, 6, and 12 months after the initial injection. Patients were classified as cured based on a negative cough test (supine and standing) and <2 g urine on 1‐hr pad test and a VAS score improved by ≥90%. Improved were those with the loss of only a few drops of urine during the cough test and 2–10 g urine on 1‐hr pad test or a reduction >50% compared with preoperative urine loss and a VAS score improved by ≥75%.

Results

The volume of PAHG injected in the current study ranged from 1–3 ml. Cured/improved rates were 93.3% (56/60), 88.3% (53/60), and 83.6% (46/55) at 1, 6, and 12 months, respectively. Patients with MUI had a cured urgency urinary incontinence rate of 36.8%, 47.4%, and 38.9%, respectively. Voiding dysfunction rates were 13.3% (8/60), 8.3% (5/60), and 1.8% (1/55) at 1, 6, and 12 months and urinary tract infection rates were 5% (3/60), 11.7% (7/60), and 3.6% (2/55), respectively. Other adverse events were short‐term and/or observed in <4% of patients.

Conclusions

PAHG can be used to treat recurrent SUI after MUS failure with good outcome and low complication rates. Neurourol. Urodynam. 36:722–726, 2017. © 2016 The Authors. Neurourology and Urodynamics published by Wiley Periodicals, Inc.     

Change of sexual function after midurethral sling procedure for stress urinary incontinence

Objectives:   To compare sexual function in women before and after the midurethral sling procedure for stress urinary incontinence (SUI).
Methods:   A total of 75 women undergoing surgery for SUI between September 2005 and September 2006 were recruited for this study. Those who completed the Female Sexual Function Index (FSFI) preoperatively and 6 months postoperatively were included in the analysis. The FSFI is a validated, 19-item questionnaire, which assesses six domains of sexual function, including desire, arousal, lubrication, orgasm, satisfaction, and pain.
Results:   Data were analyzed for 47 patients. Overall sexual function after the midurethral sling procedure was not significantly different. There were no significant differences in overall sexual function or any of the individual FSFI domain scores between patients with and without concomitant posterior colporrhaphy. There were no significant differences in sexual function between the transobturator and the retropubic surgical routes.
Conclusions:   There is no significant change in overall sexual function in women undergoing the midurethral sling procedure. Posterior colporrhaphy and operative methods do not affect overall sexual function.     

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.     

The role of provider volume on outcomes after sling surgery for stress urinary incontinence

PURPOSE: Studies of various surgical procedures have documented a relationship between provider volume and outcomes, suggesting that providers who perform a high volume of procedures provide better quality of care. We ascertained whether this relationship held in sling surgery for urinary incontinence. MATERIALS AND METHODS: We analyzed the 1999 to 2001 Medicare Public Use Files provided by the Centers for Medicare and Medicaid Services for a 5% national random sample of beneficiaries. Women undergoing pubovaginal sling procedures between July 1, 1999 and December 31, 2000 (the index period) were identified and followed for 12 months. The number of slings performed was stratified empirically by cumulative surgeon volume. Main outcomes measures included postoperative complications, concomitant or delayed prolapse repair, outlet obstruction and repeat incontinence surgery. RESULTS: Among the 5% of Medicare beneficiaries analyzed during the index period 1,356 sling procedures were performed. This extrapolates to 27,120 slings in the entire Medicare population. High volume providers (upper 24th percentile) performed significantly more prolapse repairs at the time of sling surgery than did low volume providers (40.8% vs 32.4%, p <0.006). Subsequently low volume providers performed almost twice the number of prolapse repairs during the first postoperative year following the index sling procedure (p <0.0001). There was no significant difference in complication rates or repeat anti-incontinence procedures between high and low volume providers. CONCLUSIONS: High volume surgeons were more likely to perform concomitant prolapse surgery at the time of sling surgery, whereas low volume providers had higher reoperation rates to correct prolapse during the first postoperative year. This suggests that high volume providers are more likely to diagnose and manage prolapse at the time of the sling, obviating the need for a second operation.     

Risk factors for failure of repeat midurethral sling surgery for recurrent or persistent stress urinary incontinence

Introduction and hypothesis

To study the outcomes following repeat midurethral sling (MUS) surgery in patients with persistent or recurrent stress urinary incontinence after failure of primary MUS surgery and risk factors for surgical failure.

Methods

The medical records of 24 patients who underwent repeat MUS surgery at a single tertiary center from January 2004 to February 2014 were reviewed. The types of MUS used for the repeat surgey were transobturator, retropubic and single incision slings. Objective cure was defined as no demonstrable involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction observed during filling cystometry, and subjective cure was defined as a negative response to Urogenital Distress Inventory six (UDI-6) question 3 during follow-up between 6 months and 1 year postoperatively. The change in the inclination angle between the urethra and pubic axis was measured with introital ultrasonography and the cotton swab test performed.

Results

The objective and subjective cure rates were 79.2 % and 75 %, respectively. There were no differences in demographics between the patients with failure of surgery and those with successful surgery. Significant independent risk factors for failure of repeat MUS surgery were a change in cotton swab angle at rest and straining of <30° (OR 4.6, 95 % CI 2.5 – 7.9°), a change in inclination angle of <30° (OR 4.6, 95 % CI 2.5 – 7.9°), intrinsic sphincter deficiency (OR 3.4, 95 % CI 1.8 – 6.1) and a mean urethral closure pressure of <60 cm H₂O (OR 2.9, 95 % CI 1.5 – 4.5). In one patient the bladder was perforated.

Conclusions

Repeat MUS surgery is safe and has a good short-term success rate, both objectively and subjectively, with independent risk factors for failure related to bladder neck hypomobility and poor urethral function.

     

Management of polypropylene mesh erosion after intravaginal midurethral sling operation for female stress urinary incontinence

The intravaginal midurethral sling operations have become a trend to treat female stress urinary incontinence. Cases of complications requiring surgical revision are rarely reported. We report on seven patients with complications necessitating surgery. Six patients with vaginal erosion were treated with transvaginal excision of migrated tape and fibrotic tissues around the vaginal wall, and one patient with bladder erosion was treated with suprapubic minimal laparotomy and transvaginal partial excision of the tension-free vaginal tape (TVT). The incidence of polypropylene mesh erosion was 1.1% in this study. All patients recovered well from our surgical intervention, except the bladder erosion patient who needed anticholinergic medication to treat postoperative urgency and urge incontinence.     

Identification of the optimal time to treat urgency after a midurethral sling procedure for stress urinary incontinence

We followed 91 patients who had undergone transobturator tension-free vaginal tape procedure on their perioperative urgency symptom for 1 year to identify risk factors and optimal time to commence further treatment in the presence of postoperative urgency. Of the 59 patients with preexisting urgency, 54.2, 35.6, and 39.0% demonstrated symptom persistence at postoperative 1, 6, and 12 months, respectively. Of the 32 patients without preoperative urgency, 3.1 and 18.8% of patients demonstrated de novo urgency at 1 and 6 months, respectively, but symptom persistence to 12 months was observed in 6.2%. Overall, urgency lasting to 12 months was observed in 25 (27.5%) of the entire cohort. Preoperative urgency [p = 0.001, odds ratio (OR) 9.583] and urgency at 1 month (p = 0.001, OR 5.124) were associated with symptom persistence to 1 year after surgery. We recommend treatment if urgency is noted at 1 month postoperatively in patients with preexisting urgency, and after 6 months for those without preoperative urgency.     

Predictors for persistent urodynamic stress incontinence following extensive pelvic reconstructive surgery with and without midurethral sling

Introduction and hypothesis

The objective of this study was to identify the predictors for persistent urodynamic stress incontinence (P-USI) in women following extensive pelvic reconstructive surgery (PRS) with and without midurethral sling (MUS).

Mmethods

A total of 1,017 women who underwent pelvic organ prolapse (POP) surgery from January 2005 to December 2013 in our institutions were analyzed. We included 349 USI women who had extensive PRS for POP stage III or more of whom 209 underwent concomitant MUS.

Results

Of the women who underwent extensive PRS without MUS, 64.3 % (90/140) developed P-USI compared to only 10.5 % (22/209) of those who had concomitant MUS. Those with concomitant MUS and PRS alone were at higher risk of developing P-USI if they had overt USI [odds ratio (OR) 2.2, 95 % confidence interval (CI) 1.3–4.0, p?=?0.014 and OR 4.7, 95 % CI 2.0–11.3, p?<?0.001, respectively], maximum urethral closure pressure (MUCP) of?<?60 cm H₂O (OR 5.0, 95 % CI 3.0–8.1, p?<?0.001 and OR 5.3, 95 % CI 2.7–10.4, p?<?0.001, respectively), and functional urethral length (FUL) of?<?2 cm (OR 5.4, 95 % CI 2.7–8.8, p?<?0.001 and OR 3.9, 95 % CI 2.4–6.9, p?<?0.001, respectively). Parity?≥?6 (OR 3.9, 95 % CI 1.7–5.2, p?<?0.001) and Prolift T (OR 3.1, 95 % CI 1.9–4, p?<?0.001) posed a higher risk of P-USI in those with concomitant surgery. Perigee and Avaulta A seemed to be protective against P-USI in those without MUS.

Conclusions

Overt USI with advanced POP together with low MUCP and FUL values have a higher risk of developing P-USI. Therefore, counseling these women is worthwhile while considering the type of mesh used.

     

Autologous transobturator midurethral sling placement: a novel outpatient procedure for female stress urinary incontinence

Introduction

We present a novel outpatient transobturator autologous rectus fascia midurethral sling procedure.

Methods

A 55-year old woman presented with stress urinary incontinence (SUI) as documented by history, physical exam, and 24-h pad test. Conservative and surgical treatment options were discussed. The patient was interested only in outpatient surgical options, however, and was adamantly opposed to any mesh procedures due to concerns regarding complications. Therefore, following an in-depth discussion and informed consent, a transobturator, autologous sling procedure was performed. The vaginal dissection was performed in the standard fashion. A rectus fascial strip measuring 7?×?1 cm rectus fascia was harvested. A trocar was passed through each obturator foramen. Fascial stay sutures were retracted through the skin incisions. The sling was then appropriately tensioned and the stay sutures tied together.

Results

The patient had an uncomplicated perioperative course. She voided spontaneously with low postvoid residual. At follow-up, she had no urinary leakage.

Conclusions

The transobturator autologous midurethral sling procedure is technically feasible and, in the short term, effective. Longer follow-up and larger series are needed to validate this procedure, which, however, may become a suitable option for patients and surgeons concerned with potential mesh complications.     

Suprapubic sling adjustment: minimally invasive method of curing recurrent stress incontinence after sling surgery

PURPOSE: Recurrent stress urinary incontinence after sling surgery is a complex problem. A minimally invasive method of correcting recurrent stress urinary incontinence after pubovaginal sling surgery is described. MATERIALS AND METHODS: We performed suprapubic sling adjustment in 10 women with recurrent stress urinary incontinence after sling surgery. Of these 10 women 4 had received antibacterial polytetrafluoroethylene patch sling, 3 an autologous dermis patch sling and 3 an autologous rectus fascia patch sling but stress incontinence recurred. To correct recurrent incontinence, a pubovaginal sling was revised by adjusting the sling tension suprapubically with the aid of a cotton swab test and bladder leak test. RESULTS: Mean followup was 13 months (range 8 to 28). Of the 10 women 9 became completely dry and 1 was greatly improved. One patient who had persistent stress incontinence generated an abdominal leak point pressure of 189 cm. H(2)O compared to a preoperative pressure of 120 cm. H(2)O. The incidence of de novo urge incontinence was 2% (2 of 10 cases). Mean resting cotton swab angle was (+) 20 and (+) 5 degrees, and mean Valsalva cotton swab angle was (+) 40 and (+) 5 preoperatively and postoperatively. Mean pad use decreased from 3 pads to less than 1 pad a day. Mean self-reported satisfaction score was 9 (range 8 to 10) on a visual analog scale. CONCLUSIONS: Pubovaginal slings may be revised safely with excellent results. Adjusting the sling tension suprapubically is a minimally invasive technique. Suprapubic sling adjustment may be performed as an intermediary step before resorting to a complete sling takedown/revision.