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.     

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.     

Analysis of risk factors associated with vaginal erosion after synthetic sling procedures for stress urinary incontinence

The goal of this study was to analyze the risk factors associated with vaginal erosion after synthetic sling procedure for stress urinary incontinence. Follow-up evaluations were at 1 week, 1 to 3 months, 6 months, and annually after the operation. The evaluations included detailed history taking, vaginal examinations, and perineal ultrasonographic urethrocystography. The vaginal erosion rate (6/239) after the synthetic sling procedure was 2.5%. We assessed the relationship between clinical features and vaginal erosion. Of these, only diabetes mellitus (DM) was a significant risk factor for vaginal erosion. Women with DM were 8.3 times more at risk than women without DM for developing vaginal erosion after synthetic sling procedure (p < 0.05). The vaginal erosion-free rate during the 24-month follow-up decreased significantly in women with DM. The rate of vaginal erosion associated with type III multifilamentous polypropylene sling (intravaginal slingplasty) is 10.7% more than that with type I monofilament polypropylene sling (such as tension-free vaginal tape and inside out transobturator vaginal tape) (p = 0.054). Women with DM should be informed that vaginal erosion is a possible complication after synthetic sling procedure.     

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.     

Transvaginal vs transobturator approach for synthetic sling placement in patients with stress urinary incontinence

We present comparative short-term experience with the transvaginal (TVT) and the transobturator (TVT-O) approaches for the treatment of stress urinary incontinence (SUI). We studied 315 women with SUI, treated with a tension-free tape placement. The TVT approach was applied in 265 women, while 50 women were treated by the TVT-O approach. The mean operation time was 25 and 17 min in the TVT and TVT-O group, respectively (p < 0.001). In the TVT group, continence rates were 87% after 1 year, while in the TVT-O group, the continence rate was 94%. Postoperative pain was reported in 14.4 and 28% of the TVT and TVT-O patients, respectively (p = 0.02). Complications such as bladder perforation, retropubic hematoma, and urinary retention took place only in the TVT group. Urinary tract infections were recorded in 20 and 8% of the TVT and TVT-O patients, respectively (p = 0.04), while vaginal erosion took place in 1.5 and 2% and de novo urgency in 14 and 8%. Both approaches show high rates of cure at the first postoperative year, while complications are less with the TVT-O procedure.     

Eleven years prospective follow-up of the tension-free vaginal tape procedure for treatment of stress urinary incontinence

The aim of this study was to evaluate the long-term effectiveness and safety of the tension-free vaginal tape (TVT) procedure. In a Nordic three-center prospective observational cohort study, 90 women with primary stress incontinence had a TVT operation performed in local anesthesia. Assessment included a 24-h pad test, a stress test, physical examination, and a visual analog scale for assessing the degree of bother. Patient's global impression of cure was obtained, and condition specific quality of life questionnaires were used. Seventy-seven percent of the initial cohort of 90 women and 89% of those alive and capable of cooperating were assessed 11.5 years after the TVT operation. Ninety percent of the women had both a negative stress test and a negative pad test being objectively cured. Subjective cure by patients global impression was found in 77%, 20% being improved and only 3% regarded the operation as a failure. No late-onset adverse effects of the operation were found, and no case of tape erosion was seen. The TVT procedure is safe and effective for more than 10 years.     

Tension-free vaginal tape sling for recurrent stress incontinence after transobturator tape sling failure

The transobturator tape (TOT) sling is a new minimally invasive technique to treat stress urinary incontinence (SUI). Short-term follow-up studies show high success rates; however, as with any surgical treatment of SUI, failures are known to occur. The treatment of recurrent or persistent stress urinary incontinence after a TOT sling is therefore a new dilemma as well. In this paper, we describe the successful use of a retropubic tension-free vaginal tape (TVT) sling in five patients after failed TOT sling. We present case series of five patients who had TOT slings placed for stress incontinence that failed and subsequently had TVT slings placed for persistent SUI. The TVT slings were placed under local/regional anesthesia without removal of the TOT sling. Retrospective chart review of office and hospital charts was completed, and both objective and subjective data were collected. Five patients had TVT slings placed 6–30 weeks after early failure of TOT slings that were placed for stress urinary incontinence. Postoperatively, all patients with urodynamic testing showed evidence of intrinsic sphincter deficiency; however, all maintained urethral mobility of 30°. All five patients had successful treatment of their incontinence with the retropubic tension-free sling procedure with a mean follow-up of 17 months. Recurrent or persistent stress urinary incontinence after TOT sling may be treated with TVT sling without removal of the TOT sling. Further studies with larger numbers and longer-term follow-up is warranted.     

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.     

经耻骨后和经闭孔尿道中段无张力悬吊术治疗女性压力性尿失禁的疗效观察

目的:观察经耻骨后和经闭孔尿道无张力悬吊术治疗女性压力性尿失禁(Stress urinary incontinence,SUI)的疗效。方法:选择女性SUI患者198例,病程2~25年,平均7.3年;年龄41~78岁,平均58.3岁。采用经耻骨后无张力阴道吊带术(tension-free vaginal tape,TVT,57例为TVT组)或经闭孔尿道下无张力吊带术(transobturator vaginal tape inside-out,TVT-O,141例为TVT-O组)进行治疗。结果:本文患者随访6~120个月,179例(90.4%)治愈,其中TVT组平均随访86个月,治愈51例(89.5%),改善4例(7%);TVT-O组平均随访38个月,治愈128例(90.7%),改善6例(4.3%);疗效不佳9例(3.5%)。TVT组2例发生膀胱穿孔(3.5%),TVT-O组3例出现腹股沟血肿伴下肢大腿根部疼痛,2例出现短期单下肢活动障碍,但经保守治疗均好转;术后拔除尿管后排尿困难5例,其中TVT组2例,TVT-O组3例,经多次下压式尿道扩张及延长保留尿管后解除梗阻、恢复正常排尿4例;TVT组中1例采用尿道扩张无效而剪断悬吊带。结论:经阴道中段无张力悬吊术(尤其是TVT-O)操作简便,疗效佳,并发症少,是治疗女性SUI的有效方法。     

Effectiveness of the TVT procedure as a repeat mid-urethra operation for treatment of stress incontinence

Introduction and hypotheses  The aim was to evaluate the long-term (5 years) effect of performing a retropubic tension-free vaginal tape (TVT) operation after a prior failed mid-urethra sling procedure and try to identify reasons for failure of the primary operation. Methods  We identified 26 women to whom a repeat mid-urethra sling procedure (using the TVT Gynecare device) had been performed. Both the primary and repeat operations were retropubic procedures. Four different tape materials had been utilized in the primary procedure. Results  Twenty women (77%) of the identified 26 women participated in the study. Seventy-five percent of the women were cured or significantly improved after the repeat TVT procedure. Reasons for failure of the primary procedure were grouped as follows: inadequate tape material (four out of 20), inadequate surgical technique (six out of 20), patients' medical condition (four out of 20), and unrecognized reasons (six out of 20). Conclusions  A retropubic mid-urethra sling operation can be considered after failed mid-urethra sling surgery.     

TVT术对尿道固有括约肌功能缺陷的女性压力性尿失禁患者的临床观察

目的:探讨TVT悬吊术治疗有尿道固有括约肌功能缺陷(ISD)的女性压力性尿失禁(SUI)患者的疗效.方法:采用TVT悬吊术治疗女性SUI患者114例,将ISD和无ISD患者的疗效进行比较.结果:114例中获得随访者110例(96.5%):无ISD者92例,治愈81例(88.0%),有效10例(10.9%),完全失败1例(1.1%);有ISD者18例,治愈12例(66.7%),有效3例(16.7%),完全失败3例(16.7%).术后有7例患者出现明显的排尿困难,其中2例为剩余尿阴性的ISD患者,差异有统计学意义.结论:TVT悬吊术是一种治疗女性SUI患者安全、有效和微创的治疗手段,对有ISD的女性SUI患者同样有效,但疗效不如无ISD的患者;特别是当患者年龄大于65岁、最大尿道关闭压小于0.981 kPa或尿道活动度小时,其治疗效果较差.TVT悬吊术治疗ISD时仍应遵循该术式的常规操作.     

Pelvic floor exercises for female stress urinary incontinence

Urinary continence is maintained by passive and active forces at the bladder neck and along the urethra. Pelvic floor exercises can improve these forces, provided there is sufficient muscular awareness, nerve supply and intact muscles. Instructions in the exercises must include a test for correct muscle use. Biofeedback methods seem superior. Patients must attend intensive repeated instruction for 2–3 months and perform daily exercises at home. All patients can benefit from pelvic floor exercises, but to save money and time various scoring systems, including grade of incontinence, menopausal state and pelvic muscle strength can be applied. Patients with mild incontinence and a strong pelvic floor prior to exercises have the best prognosis. Long-term follow-up after exercises shows a cure rate of 50% for stress incontinence, but this depends on the continuation rate of exercise performance. A sustained effect demands continuous or repeated exercises and attempts to protect the pelvic floor.     

犬压力性尿失禁模型的建立

目的 建立一种雌犬压力性尿失禁(SUI)模型.方法 将9条雌犬随机分为2组,A组4条离断耻骨尿道韧带、切除尿道腹侧及左右侧的纤维结缔组织和脂肪组织,如未出现尿失禁,最终将尿道左右侧、腹侧以及尿道阴道间组织全部切除;B组5条切除尿道阴道间及尿道左右侧的纤维结缔组织和脂肪组织,如未出现尿失禁,再次手术切除尿道左右侧及尿道阴道间因粘连形成的瘢痕组织.结果 A组中3条出现尿失禁,B组全部出现尿失禁.结论 通过切除尿道周围支持组织来建立雌犬压力性尿失禁模型可行,有成功率高、可直接观察等优点.阴道及尿道阴道间组织在尿控上的作用可能比尿道腹侧组织更大.     

Need for sling surgery in patients with large cystoceles and masked stress urinary incontinence

BACKGROUND: We studied the need for sling surgery in patients who suffered from large cystoceles and masked stress urinary incontinence. METHODS: Twenty patients who had large cystoceles but neither evidence nor history of stress incontinence were enrolled in this study. The cystocele was reduced using a reducing device. Masked urinary incontinence was identified by a 60 m pad weighing test and a stress test. The cystocele was reduced using a pessary ring in 14 patients, or a vaginal pack formed of two rolls of ordinary 28 x 28 cm gauze in six patients. Ten of 20 patients were diagnosed with masked stress urinary incontinence and were treated with anterior colporrhaphy and a suburethral sling procedure. The other 10 patients were continent after use of a cystocele reducing device and were treated with anterior colporrhaphy alone. Average follow-up periods of the patients with or without masked stress urinary incontinence were 51.2 months (range, 24.0-72.0 months) or 57.6 months (range, 27.0-70.0 months), respectively. RESULTS: One of the 10 patients diagnosed with masked stress incontinence had mild stress urinary incontinence postoperatively. None of the 10 continent patients had stress incontinence after anterior colporrhaphy alone. CONCLUSIONS: Reducing devices of protruding cystocele were clinically useful in the detection of masked stress incontinence. Sling surgery was effective to prevent emerging stress urinary incontinence for patients who suffered from cystocele and masked stress incontinence.     

Polytetrafluoroethylene patch sling for type 2 or type 3 stress urinary incontinence

BACKGROUND: Surgical success rates and complications of anti-incontinence surgery were evaluated according to the type of stress incontinence and the type of surgery. METHODS: From 1989 to 1998, we treated 137 women for stress urinary incontinence with anti-incontinence surgery. Of the 137 patients, 110 had type 2 stress urinary incontinence and 27 had type 3 stress urinary incontinence. Of 110 patients with type 2 stress urinary incontinence, 57 underwent pubovaginal sling procedure and 53 were treated with the Gittes procedure. All of the patients with type 3 stress urinary incontinence underwent the pubovaginal sling procedure. RESULTS: Cure rates with the pubovaginal sling procedure were 82% in type 2 incontinence and 70% in type 3 incontinence. Cure rates with the Gittes procedure were 56%. The occurrence of de novo urge symptom and pelvic pain was low and bore no relation to either operative method or type of stress incontinence. CONCLUSIONS: The pubovaginal sling procedure using the polytetrafluoroethylene patch was effective for type 2 or 3 stress urinary incontinence.     

经耻骨后与经闭孔尿道吊带术治疗女性压力性尿失禁中远期疗效比较

目的 探讨经耻骨后(SPARC)与经闭孔(TOT)路径尿道吊带术治疗女性压力性尿失禁(SUI)的中远期疗效及安全性.方法 回顾性分析2008年9月至2011年1月收治尿动力学资料完整的SUI患者275例,分别行SPARC吊带术(136例)和TOT吊带术(139例).随访3～ 28个月,平均19.4个月.填写国际尿失禁咨询委员会尿失禁问卷简表(ICI-Q-SF),国际盆底器官脱垂/尿失禁患者性生活质量问卷简表(PISQ-12),分组测量膀胱残余尿量(PVR)、最大尿流率(Qmax),比较两种术式的中长期疗效和并发症.结果 ①TOT组手术时间(25.1±3.3) min,SPARC组(34.8±5.6) min,组间差异有统计学意义(P=0.00);②TOT组症状评分由术前(7.0±1.9)分降至末次随访(0.4±1.2)分,QOL评分由术前(6.2±2.0)分降至(1.1±1.4)分;SPARC组症状评分由(7.2±2.1)分降至末次随访(0.6±1.7)分,QOL评分由(6.6±2.0)分降至(1.0±1.6)分;2组评分与术前比较差异均有统计学意义(P=0.00).TOT组有性生活患者PISQ-12评分由术前(24.2±5.0)分增至末次随访(29.5±4.8)分,SPARC组由(23.0±4.4)分增至(26.9±4.8)分,与术前比较差异均有统计学意义(P＜0.05).TOT组总治愈率89.9％,有效率94.2％;SPARC组总治愈率89.0％,有效率91.2％,2组比较差异无统计学意义(P＞0.05).③TOT组术后短期排尿障碍23例,SPARC组20例,均于术后1～2周内缓解.④TOT组和SPARC组术前Qmax分别为(30.2±8.7)、(31.7±9.4)ml/s,术后1周内降至(24.9±8.6)、(26.9±8.9)ml/s;PVR分别由术前(1.6±4.2)、(1.4±3.7)ml增至术后(3.2±6.5)、(3.5±6.3)ml,手术前后差异均有统计学意义(P＜0.05).TOT组患者术后3个月(109例)Qmax为(31.5±8.2)ml/s,PVR(2.6±5.4) ml;术后12个月(69例)Qmax为(29.2±7.9) ml/s,PVR(3.2±7.3)ml;术后≥24个月(30例)Qamx为(27.6±9.4)ml/s,PVR(7.4±9.4)ml;随访阶段数据与术前比较差异无统计学意义(P＞0.05).SPARC组患者术后3个月(106例)Qmax为(29.2±8.9) ml/s,PVR(3.6±7.2) ml;术后12个月(65例)Qmax为(28.2±8.3)ml/s,PVR(4.6±7.2)ml;与术前比较差异均无统计学意义(P＞0.05).但SPARC组术后≥24个月患者(30例)Qmax为(26.2±9.1 )ml/s,PVR为(4.7±8.8)ml,与术前相比差异均有统计学意义(P＜0.05).结论 经闭孔路径及经耻骨后路径尿道吊带术治疗SUI中、远期疗效均满意,但前者在安全性、微创及并发症等方面更有优势.     

女性尿道括约肌控尿和压力性尿失禁发病的机制

女性尿道括约肌控尿机制和压力性尿失禁发病机理的研究经历了长期和曲折的过程,目前认为,女性尿道括约肌是由尿道横纹肌括约肌、尿道平滑肌括约肌和尿道固有膜等结构,共同参与组成的一个构造精细而有序的尿道括约肌复合体或称尿道括约肌系统.压力性尿失禁的发生主要与尿道括约肌本身解剖结构和功能缺陷,以及尿道周围附属结构和支撑结构缺陷有关.