Results of various operations for urinary stress incontinence

Four hundred and eleven women with urinary incontinence were studied and treated over a 12-year period. The surgical procedures undertaken included 45 colporrahies with Kelly stitches, 12 interposition operations, 49 fascial slings, 49 Zoedler slings using Mersilene, 66 slings using dura, 136 retropubic colpourethrocystopexies, and 54 other operations. Retropubic operations, such as colpourethrocystopexy, should be considered the primary operation for stress incontinence, for if correctly executed, they give the best long-term cure rate (97%).     

Comparative urodynamic studies of women with prolapse and stress incontinence before and after abdomino-vaginal sling urethro-plasty

The effect of abdomino-vaginal sling urethro-plasty according to lyodura slings on the intravesical and intraurethral pressure was evaluated in 25 women with prolapse and stress incontinence. The investigations including a gynecological examination, urine and simultaneous urethro-cystometry. Prior to the operation, all incontinent women had a negative urethral closure pressure at stress. After surgery all 25 patients reported continence, which was confirmed by positive urethral closure pressures. The urethral pressure at rest was significantly decreased in all patients 2 weeks after operation but returned to the same value 1 year after surgery as before surgery. The functional and the absolute urethral lengths increased minimally after the operation.     

Sling distress: a subanalysis of the IVS tapes from the SUSPEND trial

AIM: To study the incidence of erosions and tape infections following the use of intravaginal slingplasty (IVS) treatment for stress urinary incontinence after the SUSPEND trial period of 30 months. This subanalysis was carried out because of concerns regarding high percentage of delayed sling erosions and infections during follow up of the patients who participated in the trial. MATERIALS AND METHODS: The subanalysis patient group consisted of all IVS patients drawn from the SUSPEND randomised control trial that compared the safety and efficacy of three types of suburethral slings, TVT, SPARC and IVS, for the treatment of urodynamic stress incontinence. RESULTS: A total of 62 patients were reviewed during this study conducted from April 2002 to May 2003. Continence was achieved in 88% the patients. A total of eight (13%) sling erosions were found requiring sling removal. Forty-eight (77.4%) patients were followed up at 12 months with one case of erosion (1.7%). Twenty-nine (46.8%) of the 62 patients were followed up between 12 and 34 months, and seven cases of sling erosions were diagnosed. One patient had purulent suprapubic sinus, five patients had foul-smelling discharge, and one had recurrent urinary tract infection associated with pain and discharge. After the slings were removed the patients had no further symptoms. However, three of them had recurrent stress urinary incontinence. DISCUSSION/CONCLUSION: The delayed presentation of the sling erosion from this subanalysis is a concern, and pelvic reconstructive surgeons using IVS need to be aware of the delayed presentations we found in our cohort of patients.     

The fascia lata suburethral sling for treating recurrent urinary stress incontinence

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of the fascia lata suburethral sling procedure in the treatment of recurrent genuine urinary stress incontinence. STUDY DESIGN: This study was a retrospective analysis of 60 patients who had a suburethral fascia lata sling placement between January 1992 and December 1995. Follow-up ranged from 6 months to 3.5 years. The database was obtained by a retrospective chart review, a written questionnaire, and telephone interview. RESULTS: Between January 1992 and December 1995, 72 patients who had at least one previous incontinence procedure were assessed by urodynamic testing and cystourethroscopic examination before undergoing a fascia lata sling placement. Of this population, 60 were available for follow-up. Of this 60, 54, or 90%, had complete cure or marked improvement in the urinary incontinence. There were six failures, two of which had no bladder neck mobility and two of which had detrusor instability and were unable to take medication because of medical contraindications. In addition, two slings were sacrificed because of postoperative complications. The most common postoperative complication was urinary retention, which resulted in eight, or 13.4%, of slings needing to be released. CONCLUSION: Our data support the use of the suburethral fascia lata sling as an effective method for the treatment of recurrent genuine urinary stress incontinence, with urinary retention being the most common postoperative complication.(Am J Obstet Gynecol 1997;177:6)     

Sling operations in the treatment of stress urinary incontinence: how to adjust sling tension

AIM: To find an objective method of adjusting sling tension in order to avoid postoperative urinary obstruction. METHODS: Thirty-five female patients with type II/III and type III stress urinary incontinence were treated using a sling procedure. Pubovaginal fascial slings were implanted in 20 patients and polytetrafluoroethylene patch slings with nylon sutures were implanted in 15 patients. During the procedures the urinary bladder was partially full and the patients, who were under spinal or epidural anesthesia, were asked to cough and strain. The proper tension that effectively prevents urine leakage was selected and the corresponding suture length was marked. An objective new method to adjust sling tension was used. As part of this method, the abdominal bulge index is added to the suture length before tying. RESULTS: Short-term follow-up of 6-12 months showed that 33 of 35 patients reported no leakage of urine (94%). Two patients had unsatisfactory urge incontinence. We did not encounter postoperative urinary retention in any patient. No significant post-voiding residual urine was reported. None of our patients in this series have complained of difficulties during micturition or the need to strain during voiding. CONCLUSION: Proper adjustment of sling tension using the abdominal bulge index has eliminated postoperative urinary retention and obstructed urine flow, including any appreciable amount of post-voiding residual urine. This method has been found to be both objective and reproducible.     

Comparison of long-term outcomes of autologous fascia lata slings with Suspend Tutoplast fascia lata allograft slings for stress incontinence

OBJECTIVE: This study was undertaken to compare the objective and subjective long-term surgical outcomes in patients receiving Tutoplast fascia lata allograft slings with those receiving autograft slings for the treatment of stress urinary incontinence (SUI). STUDY DESIGN: We reviewed all patients (n = 71) undergoing suburethral sling with either autologous fascia lata (n = 39) or Tutoplast fascia lata (n = 32) for urodynamic stress incontinence (USI) from October 1, 1998, to August 1, 2001. RESULTS: Of the original 71 patients, 47 were evaluated by objective and/or subjective means at a minimum of 2 years after surgery. Subjective quality of life measures, subjective continence, maximum urethral closure pressure, and bladder neck mobility were not different between the 2 groups. USI was demonstrated in 41.7% of allograft patients compared with no autograft patients (P = .007). CONCLUSION: Although patient reported cure of SUI is high for both sling types, USI recurs at a significantly higher rate in Tutoplast slings compared with autologous slings.     

A minimally invasive technique for relaxing overtentioned midurethral slings

Midurethral slings for stress urinary incontinence are effective surgical treatment with substantial rate of postoperative urinary retention. Different operative procedures ranging from urethrolysis to midline sling incision have been described to correct these cases. In this letter, we describe a minimally invasive technique for loosening overtensioned midurethral slings.     

Use of the Urethral Sling to Treat Symptoms of Climacturia in Men After Radical Prostatectomy

BackgroundClimacturia affects up to 45% of men after radical prostatectomy (RP). Although urethral slings decrease the severity and frequency of stress incontinence after RP, their efficacy as a treatment for climacturia after RP has not been well studied.AimThe aim of this study was to assess patient-reported changes in climacturia symptoms after implantation of a urethral sling as a treatment for stress incontinence after RP.MethodsAfter Institutional Review Board approval, a retrospective chart review identified males aged 18–80 years who received urethral slings for stress incontinence after RP at our institution from 2012 to 2017. These patients were mailed an 11-item questionnaire asking them about climacturia symptoms before and after implantation of a urethral sling. Written informed consent was obtained from patients participating in the mailed questionnaire.OutcomesRespondents were asked to report on climacturia frequency and severity, bother, partner bother, and incontinence before and after implantation of urethral slings.ResultsA total of 42 questionnaires were mailed; 17 were available for analysis. The median age (and interquartile range, IQR) of the sample at RP was 64 (59.5, 68.0). Almost all (94.1%) of the men were sexually active at the time of the study and 64.7% reported experiencing urinary leakage during sexual arousal. Most (58.8%) underwent the urethral sling procedure to treat general incontinence; 35.3% underwent the procedure to treat both general incontinence and incontinence during sexual activity and 1 (5.9%) underwent it for other reasons. A median of 28.1 months elapsed between RP and sling procedure (IQR: 18.36, 53.88; minimum: 8.00; maximum: 108.36). Statistically significant shifts toward improvement from presling to postsling were noted for frequency of leakage during sexual arousal or orgasm (P = .041) and for the degree to which leakage of urine during sexual arousal or orgasm was a “bother” (P = .027). While almost all (94%) of the men were incontinent before sling, this percentage dropped to 53% after sling (P = .031).Clinical ImplicationsUrethral slings should be discussed as a treatment strategy for climacturia during clinical consultations with patients.Strengths & LimitationsStrengths include consistent surgical technique. Limitations include retrospective design, lack of a nonsling comparison group, subjective nature of outcome measures, possible response bias, and variability in time interval between RP and sling procedure.ConclusionUse of urethral slings after RP is associated with improvements in climacturia symptoms, bother, and incontinence.Nolan J, Kershen R, Staff I, et al. Use of the Urethral Sling to Treat Symptoms of Climacturia in Men After Radical Prostatectomy. J Sex Med 2020;17:1203–1206.     

Surgical treatment of stress urinary incontinence by suburethral transobturator tape

OBJECTIVE: Assessment of the suburethral transobturator tape in the treatment of female urinary stress incontinence. PATIENTS AND METHODS: Retrospective evaluation of 39 slings. Three patients (7%) were lost to follow-up. Analysis was carried on 19 out/in procedures (mainly ObTape and Uratape slings) and 17 in/out procedures (TVT-O slings). Nine patients (25%) had a history of previous stress incontinence surgery. In 21 cases (58%) there was a concomitant surgical procedure, including genital prolapse repair (12) and total hysterectomy (6). Phone interviews were conducted with the validated questionnaires MHU and Ditrovie short form. RESULTS: The mean operative time was 17 minutes (10-30). Three vaginal wounds (8%) were immediately repaired. Two urinary retentions (5%) were managed by suprapubic catheterization for more than 10 days. With a mean follow-up of 12 months (4-23) the subjective effectiveness on stress incontinence was 89% (cure: 58%; improvement: 31%). Urge incontinence symptoms were cured in 47% of mixed incontinences. Two patients reported an important dysuria. Two sling exposures occurred. Quality of life scores were significantly improved (mean 1,7 versus 3,2, p=0,002). The level of satisfaction reached 89% (very satisfied: 50%; satisfied: 39%). DISCUSSION AND CONCLUSION: This technique is safe and effective. Our results are nevertheless inferior to those previously reported. Prospective randomised studies comparing the two surgical routes are required.     

Neue Entwicklung vaginaler Inkontinenzoperationen

Vaginal repair has long been the procedure of choice for gynecologists to treat female urinary incontinence. High failure and recurrence rates in objectively controlled studies have guided towards abdominal procedures such as colposuspension and traditional slings. Tension-free vaginal tape (TVT) has proven to be an excellent choice in female stress urinary incontinence without prolapse or other pathology, especially in patients at risk. Severe paravaginal defects and additional pathology leave a wide spectrum for the traditional colposuspension. Further long-term follow-up and comparative studies will have to show whether the good results with TVT can be stabilized and which complications with the alloplastic sling material might arise. With many questions unanswered, we are very cautious with implanting TVT in very young women.     

Recent Advances in Tape Slings for Female Urinary Stress Incontinence

Sling therapy is the enhanced surgical support of the urethra. In this article, the history of the use of slings for the surgical treatment of female urinary stress incontinence is reviewed, and the usual surgical routes for retropubic (transvaginal) or transobturator tape passage are described. The latest innovation in sling therapy is the use of minislings, which are short tape mesh implants inserted through a single vaginal incision; these slings may be placed in an office setting. Outcomes data are either lacking or suggest a considerable decrement of effectiveness of unstabilized minislings over full-length slings; however, the short-term efficacy of a stabilized, adjustable minisling is 97%. These results suggest benchmark effectiveness associated with full-length slings in a less invasive device that also has the capability of short-term adjustability.Key words: Minisling, Urinary stress incontinence, Retropubic sling, Transvaginal tape, Subfascial or transobturator sling, Suburethral slingUrodynamic stress incontinence (USI) is the leakage of urine through an incompetent urethra in the absence of a detrusor contraction.¹ The purest symptom of USI is urinary loss upon raising intra-abdominal pressure, as in coughing. Ten percent of middle-aged women report weekly incontinence,² although only 1 in 1000 women undergo curative surgery. USI may be complicated by intrinsic sphincter deficiency (ISD), detrusor overactivity or voiding disorder, or pelvic organ prolapse. USI is amenable to physical therapy and to surgery. Drug therapy to remedy a structural defect has been understandably disappointing. Bulking agents have a role in treating women with ISD, those who have undergone repeat surgery, or those medically unfit for surgery.     

Management of stress urinary incontinence

Stress urinary incontinence is a common condition that can severely affect a woman's quality of life. Midurethral slings (tension-free vaginal tape and transobturator tape) are becoming first-line surgical treatments for stress urinary incontinence in women. Both procedures gained worldwide popularity immediately after they were introduced. Short operative time, brief hospitalization period, and ease of application have played a role in their acceptance. Sufficient data support the use of both retropubic and transobturator approaches for the placement of a midurethral sling. However, longer follow up in larger populations should assess the long-term reliability of these procedures.     

Longitudinal study of Pelvicol pubovaginal slings using magnetic resonance imaging.

The mechanism of urinary continence is complicated and is poorly understood. One current opinion is that there is an absence or weakness of the endopelvic fascial supports of the urethra. Pubovaginal slings are rapidly becoming the surgical procedure of choice in the management of urodynamic stress incontinence but their method of action is unclear. This study using magnetic resonance imaging shows how a pubovaginal sling can restore the normal anatomy and continence and adds to the global understanding of this condition.     

Stress urinary incontinence

Stress urinary incontinence, the complaint of involuntary leakage during effort or exertion, occurs at least weekly in one third of adult women. The basic evaluation of women with stress urinary incontinence includes a history, physical examination, cough stress test, voiding diary, postvoid residual urine volume, and urinalysis. Formal urodynamics testing may help guide clinical care, but whether urodynamics improves or predicts the outcome of incontinence treatment is not yet clear. The distinction between urodynamic stress incontinence associated with hypermobility and urodynamic stress incontinence associated with intrinsic sphincter deficiency should be viewed as a continuum, rather than a dichotomy, of urethral function. Initial treatment should include behavioral changes and pelvic floor muscle training. Estrogen is not indicated to treat stress urinary incontinence. Bladder training, vaginal devices, and urethral inserts also may reduce stress incontinence. Bulking agents reduce leakage, but effectiveness generally decreases after 1-2 years. Surgical procedures are more likely to cure stress urinary incontinence than nonsurgical procedures but are associated with more adverse events. Based on available evidence at this time, colposuspension (such as Burch) and pubovaginal sling (including the newer midurethral synthetic slings) are the most effective surgical treatments.     

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.     

Single incision slings: Past,present, and future

Pubovaginal slings have become the gold standard to treat stress urinary incontinence. Traditionally, the sling referred to a suspensory that was placed under the urethra and brought through the retropubic space and anchored on either side of the midline. Since this original concept, there have been many materials used for the sling, and there have been many different anchoring approaches. Most agree that one of the best materials is polypropylene mesh. However, the means of anchoring the device and where best to have this anchorage placed is debatable. The options for anchoring simply include using darts vs not to hold the sling in place. The location of this anchorage, on the other hand, is much more controversial. The main locations are retropubic, transobturator, and via a single incision. The obturator and retropubic slings have become the standard of care over time. The single incision sling, on the other hand, is starting to be more acceptable which has resulted in it being used more frequently. The single incision relies on mainly anchoring the sling through the obturator internus muscle with possible inclusion of the obturator membrane. The purpose of this review article is to present the data that exists for the use of the single incision sling.     

Surgical options in the treatment of stress urinary incontinence in women

The aim of this review is to provide an update on the surgical options for treatment of stress incontinence in women. The efficiency of different procedures and the safety associated with each procedure are evaluated, mainly by reviewing the randomised controlled trials. The open retropubic colposuspension and the sling procedures are the most efficacious for treatment stress urinary incontinence especially in the long term. The laparoscopic colposuspension may be as good as the open colposuspension, but the long-term performance remains uncertain. The newer minimal access vaginal sling procedures appear to offer benefits of minimal access surgery with success rate similar to the colposuspension and the traditional slings and minor morbidity in the short and median-term. However long term data is still awaited. The transobturator technique does not seem to provide advantages compared to the classical TVT procedure. Urethral injection therapy does not seem to have the same efficacy as conventional surgery and long term data is still scanty. However, because of low operative morbidity it represents a favourable alternative to standard surgery in patients who prefer less invasive treatment, the frail elderly and other selected women where conventional surgery is problematic.     

Autologous Fascial Slings for Surgical Management of Stress Urinary Incontinence: A Come Back

Stress urinary incontinence (SUI) is a common type of urinary incontinence adversely affecting the quality of life of women. For mild SUI, life style changes, pelvic floor exercises and medical treatment with duloxetine may help. Most patients of moderate to severe SUI usually require surgical treatment. Various surgical treatment options include Kelly’s plication, Burch colposuspension, bulking agents and sling surgeries. Although, suburethral fascial slings including the autologous rectus fascia slings were in vogue before 1990, they were overtaken by minimally invasive, faster and easier artificial midurethral slings (tension free vaginal tape and transobturator tape). However, observation of serious long-term and life changing complications of synthetic midurethral slings like mesh erosion, chronic pelvic pain and dyspareunia led to their adverse publicity and medico legal implications for the operating surgeons. This led US FDA (Food and Drug Administration) to issue a warning against their use. Currently, their use has significantly decreased in many countries, and they are no longer available in some countries. This has led to renaissance of use of natural autologous fascial sling, especially rectus fascia for surgical management of SUI. Although performing rectus fascia sling surgery is technically more challenging, takes longer, has more short-term morbidity like voiding dysfunction, their long-term success is high with very little risk of serious complications like mesh erosion, chronic pelvic pain and dyspareunia. However, multicentric trials and longer follow ups are needed before it’s routine recommendation This review discusses the role of autologous fascial sling (especially rectus fascia) for the surgical management of SUI in the current time and the need of ongoing training of this procedure to gynecology residents and urogynecology fellows.     

The fascia lata sling procedure for treating recurrent genuine stress incontinence of urine

The fascia lata sling procedure has been used over the past 22 years in our unit for treating recurrent urinary stress incontinence when irreparably poor local support tissues were suspected. Sixty-nine patients had undergone one previous operation to correct urinary stress incontinence. One hundred one patients had two or more previous operations. The cure rate for the condition of genuine stress incontinence has been 100% in the last 148 cases and 98.2% overall. However, the cure rate for the symptom of urinary stress incontinence was 92.4%. There were only three sling failures in the entire series, occurring in the first 22 cases. Ten other patients had urinary incontinence with stress because of motor urge incontinence. The most troublesome postoperative problem has been delayed voiding.     

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。