Updated Systematic Review and Meta-Analysis of the Comparative Data on Colposuspensions,Pubovaginal Slings,and Midurethral Tapes in the Surgical Treatment of Female Stress Urinary Incontinence

Context

Burch colposuspension, pubovaginal sling, and midurethral retropubic tape (RT) and transobturator tape (TOT) have been the most popular surgical treatments for female stress urinary incontinence (SUI). Several randomized controlled trials (RCTs) have been published comparing the different techniques, with conflicting results.

Objective

Our aim was to evaluate the efficacy, complication, and reoperation rates of midurethral tapes compared with other surgical treatments for female SUI.

Evidence acquisition

A systematic review of the literature was performed using the Medline, Embase, Scopus, Web of Science databases, and Cochrane Database of Systematic Reviews.

Evidence synthesis

Thirty-nine RCTs were identified. Patients receiving midurethral tapes had significantly higher overall (odds ratio [OR]: 0.61; confidence interval [CI]: 0.46–0.82; p = 0.00009) and objective (OR: 0.38; CI: 0.25–0.57; p < 0.0001) cure rates than those receiving Burch colposuspension, although they had a higher risk of bladder perforations (OR: 4.94; CI: 2.09–11.68; p = 0.00003). Patients undergoing midurethral tapes and pubovaginal slings had similar cure rates, although the latter were slightly more likely to experience storage lower urinary tract symptoms (LUTS) (OR: 0.31; CI: 0.10–0.94; p = 0.04) and had a higher reoperation rate (OR: 0.31; CI: 0.12–0.82; p = 0.02). Patients treated with RT had slightly higher objective cure rates (OR: 0.8;CI: 0.65–0.99; p = 0.04) than those treated with TOT; however, subjective cure rates were similar, and patients treated with TOT had a much lower risk of bladder and vaginal perforations (OR: 2.5; CI: 1.75–3.57; p < 0.00001), hematoma (OR: 2.62; CI: 1.35–5.08; p = 0.005), and storage LUTS (OR: 1.35; CI: 1.05–1.72; p = 0.02). Meta-analysis demonstrated similar outcomes for TVT-O (University of Liège, Liège, Wallonia, Belgium) and Monarc (AMS, Minnetonka, MN, USA).

Conclusions

Patients treated with RT experienced slightly higher continence rates than those treated with Burch colposuspension, but they faced a much higher risk of intraoperative complications. RT and pubovaginal slings were similarly effective, although patients with pubovaginal slings were more likely to experience storage LUTS. The use of RT was followed by objective cure rates slightly higher than TOT, but subjective cure rates were similar. TOT had a lower risk of bladder and vaginal perforations and storage LUTS than RT. The strength of these findings is limited by the heterogeneity of the outcome measures and the short length of follow-up.     

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.     

Five-year Results of a Randomized Trial Comparing Retropubic and Transobturator Midurethral Slings for Stress Incontinence

Background

Midurethral slings have become the most preferred surgical treatment for female urinary incontinence.

Objective

To compare the efficacy and safety of two midurethral sling procedures with a different technique of sling insertion 5 yr after intervention.

Design, setting, and participants

Multicenter randomized clinical trial conducted in seven public hospitals in Finland including primary cases of stress urinary incontinence.

Intervention

Surgical treatment with the retropubic tension-free vaginal tape (TVT) procedure or the transobturator tension-free vaginal tape (TVT-O) procedure.

Outcome measurements and statistical analysis

Objective treatment success criteria were a negative stress test, a negative 24-h pad test, and no retreatment for stress incontinence. Patient satisfaction was assessed by condition-specific quality-of-life questionnaires.

Results and limitations

A total of 95% of the included women could be assessed according to the protocol 5 yr after surgery. The objective cure rate was 84.7% in the TVT group and 86.2% in the TVT-O group, with no statistical difference between the groups. Subjective treatment satisfaction was 94.2% in the TVT group and 91.7% in the TVT-O group, with no difference between groups. Complication rates were low, with no difference between groups.

Conclusions

Both objective and subjective cure rates were >80% in both groups even when women lost to follow-up were included as failures. The complication rates were low, with no difference between the groups. No late-onset adverse effects of the tape material were seen.

Patient summary

Female urinary stress incontinence can be treated surgically with minimally invasive midurethral sling procedures. Two main approaches of sling placement have been developed: the retropubic and the transobturatory. We compared both approaches and followed the patients for 5 yr. We found no difference in cure rate between the procedures, and patient satisfaction was high.

Trial registration

ClinicalTrials.gov identifier NCT00379314.     

Tension-Free Vaginal Tape Versus Transobturator Suburethral Tape: Five-Year Follow-up Results of a Prospective,Randomised Trial

Background

Many studies have assessed the equivalent effectiveness of tension-free vaginal tape (TVT) and transobturator suburethral tape (TVT-O) at short- to medium-term follow-up, but no long-term randomised trials appear in the literature.

Objective

We compared the use of TVT to TVT-O, providing a longer follow-up than currently appears in the literature.

Design, setting, and participants

Seventy-two consecutive patients affected by stress urinary incontinence (SUI) were included in this randomised, controlled trial. Patients were randomly allocated to the TVT or TVT-O procedure using a predetermined, computer-generated randomisation code.

Intervention

After preoperative assessment, patients were randomly allocated to the TVT or TVT-O procedure.

Measurements

This 5-yr study represents the extension of our original randomised trial, which was designed to assess the incidence of long-term complications (primary end point) and successes (secondary end point) for both techniques.

Results and limitations

At 60-mo follow-up, 52 patients (72%) were objectively cured of SUI (72.9% after TVT-O and 71.4% after TVT), but only 44 patients (61%) were satisfied. The late complication rate was 16.6% (10 women): five women (16.1%) in the TVT-O group and five women (17.2%) in the TVT group (p = 1). In this follow-up, 62% of the patients from the TVT-O group and 60% from the TVT group (p = 1) expressed that they were satisfied or very satisfied with the results. The mean cause of dissatisfaction was the development of sexual dysfunction resulting from dyspareunia or incontinence during intercourse, which was found in 6 of 16 dissatisfied patients (37.5%). The limitations of our study included the adequate but small sample size and the lack of questionnaires.

Conclusions

Both surgical techniques are safe, with similar results (72.9% and 71% of patients objectively cured after TVT-O and TVT, respectively) and low complication rates (16.6%: 16.1% and 17.2%, respectively, for TVT-0 and TVT), even after 5-yr follow-up.     

The Clinical Effectiveness of Retropubic (IVS-02) and Transobturator (IVS-04) Midurethral Slings: Randomized Trial

Background

Few series comparing the clinical efficacy of retropubic slings versus transobturator slings for the treatment of female stress urinary incontinence (SUI) are available.

Objective

To compare clinical efficacy of retropubic tape operations and transobturator suburethral tape operations for the surgical treatment of female SUI.

Design, setting, and participants

From January 2003 to December 2005, 611 patients underwent clinical and urodynamic evaluation before surgical treatment for SUI. Patients with advanced urogenital prolapse (pelvic organ prolapse-quantification scale [POP-Q] scale grade >1) were excluded, and 537 patients were included in this study. After 18 mo, 398 women were available for follow-up efficacy evaluation at a tertiary academic center.

Intervention

All patients underwent either a retropubic sling procedure or a transobturator sling procedure. Patients were randomly allocated into two study groups at a ratio of 1:1.

Measurements

After 18 mo all enrolled patients were clinically checked for clinical efficacy of both procedures.

Results and limitations

Demographic and urodynamic parameters of patients were similar in both groups. No bladder injury occurred in the transobturator sling group (IVS-04), whereas 13 intraoperational bladder perforations (6.5%) occurred in the retropubic sling group (IVS-02) (p < 0.001). The tape erosion rate was <2.5% in both groups (p = 0.7). After 18 mo, 398 patients (201 in the IVS-02 group and 197 in the IVS-04 group) were evaluated in terms of clinical efficacy of the procedures. We found out that there was no statistically significant difference in clinical efficacy between these two procedures (χ² = 1.88, p = 0.39). In the IVS-02 group, 75.1% of patients (n = 151) remained dry (cured), 16.9% of patients (n = 34) reported significant improvement, and 8.0% of patients (n = 16) were considered as failures. In the IVS-04 group, 74.1% of patients (n = 146) remained dry, 14.2% of patients (n = 28) reported significant improvement, and 11.7% (n = 23) were considered as failures.

Conclusions

Based on an 18-mo follow-up, the efficacies of both techniques are comparable; however, the retropubic route appears to be more efficient in the intrinsic sphincter deficiency (ISD) group.     

Tension-free midurethral slings in the treatment of female stress urinary incontinence: a systematic review and meta-analysis of randomized controlled trials of effectiveness

OBJECTIVES: To evaluate the efficacy of tension-free vaginal tape (TVT) compared with other surgical treatments for stress urinary incontinence (SUI) and with other tension-free midurethral slings. METHODS: A systematic review of the literature was performed in January 2007 using MEDLINE, Embase, and Web of Science. The searches used both "MeSH" and "free text" protocols. Meta-analysis was conducted using the Review Manager software 4.2 (Cochrane Collaboration). RESULTS: Our search identified 37 randomized controlled trials. According to the Jadad score, the quality of the evaluated studies was limited in most papers. TVT outperformed Burch colposuspension in terms of postoperative continence rates (odds ratio [OR] from 0.38 to 0.59, according to the different end points), whereas success rates were similar after TVT and pubovaginal slings. Comparing TVT to the other retropubic tension-free midurethral vaginal slings, TVT was more efficacious than both intravaginal slingplasty (IVS; OR = 0.47; p = 0.007) and suprapubic arc (SPARC; OR from 0.53 to 0.56 according to the different evaluated end points). Indeed, the available data suggest similar efficacy for retropubic and trans-obturator tapes both in terms of subjective (OR = 0.98; p = 0.92) and objective (OR = 0.81; p = 0.34) cure rates. CONCLUSIONS: Our meta-analysis showed that TVT outperformed Burch colposuspension; efficacies of TVT and pubovaginal sling were similar. TVT was more efficacious than IVS and SPARC, whereas retropubic and trans-obturator tapes showed overlapping cure rates. The poor quality of most of the studies, both in terms of methodologic and clinical parameters, limits the strengths of the recommendations derived by the meta-analysis.     

A Randomized Comparison of a Single-incision Midurethral Sling and a Transobturator Midurethral Sling in Women with Stress Urinary Incontinence: Results of 12-mo Follow-up

Background

Midurethral sling procedures have become the prime surgical treatment for women with stress urinary incontinence (SUI). Single-incision mini-slings (SIMS) potentially offer similar efficacy with reduced morbidity. This international multicenter trial compared the efficacy and morbidity of a SIMS (MiniArc) and a transobturator standard midurethral sling (SMUS) (Monarc).

Objective

To compare subjective and objective cure, morbidity, and surgery-related discomfort following SIMS and transobturator SMUS.

Design, setting, and participants

Prospective randomized controlled trial with an initial follow-up period of 12 mo. Women with symptomatic SUI were eligible.

Outcome measurements and statistical analysis

Primary outcome was subjective cure, defined as an improvement on the Patient Global Impression of Improvement (PGI-I). Coprimary outcome was the mean visual analog scale (VAS) pain score (0–100) during 3 d after surgery. Secondary outcomes were objective cure based on the cough stress test (CST), disease-specific quality of life determined by the Urogenital Distress Inventory (UDI-6) score, surgical parameters, and physical performance during recovery. Analysis was by intent to treat. Differences between the MiniArc and Monarc groups on dichotomous variables were chi-square tested and presented as relative risks (RR) with corresponding 95% confidence intervals. We hypothesized that MiniArc was noninferior to Monarc concerning subjective cure and superior concerning postoperative pain.

Results and limitations

We randomized 97 women to MiniArc and 96 to Monarc. At 12-mo follow-up, subjective cure was 83% following MiniArc and 86% following Monarc (p = 0.46). Objective cure was 89% following MiniArc and 91% following Monarc (p = 0.65). The mean pain VAS score during the first three postoperative days was 9 following MiniArc and 22 following Monarc (Mann-Whitney U test, p < 0.01).

Conclusions

At 1-yr follow-up, MiniArc was noninferior to Monarc with respect to subjective and objective cure and superior with respect to postoperative pain.

Patient summary

This 1-yr randomized clinical trial showed that MiniArc, a single-incision midurethral sling, is noninferior to Monarc, a transobturator sling, with respect to cure and superior with respect to pain and recovery.     

Tension-Free Vaginal Tape in the Management of Recurrent Urodynamic Stress Incontinence after Previous Failed Midurethral Tape

Background

Data about the use of tension-free vaginal tape (TVT) in the management of recurrent urodynamic stress incontinence (RUSI) after previous failed midurethral sling procedure (MUSP) are limited.

Objective

Assessment of the efficacy and the indications of the TVT procedure in the management of patients with RUSI after failed previous MUSP.

Design, setting, and participants

Thirty-one patients with RUSI after previous failed MUSP were prospectively enrolled at a single tertiary academic center.

Measurements

Preoperatively and postoperatively, patients were assessed with physical examination, urinalysis, urine culture, bladder diary for 2–3 d, Q-tip test, uroflow, filling and voiding cystometry, urethral profilometry, and 1-h pad test. Mean follow-up was at 18.6 mo (range: 12–28 mo).

Results and limitations

Overall, the objective cure rate based on the pad test findings was 74%, the improvement rate was 6.5%, and the failure rate was 19.5%. The objective cure rate based on cough stress test during filling cystometry was 77.4%, and the subjective cure rate based on patients’ answers was 71%. The study could have some limitations. The relatively small number of patients enrolled could affect the findings of study to some degree. Additionally, because urethral pressure profiles show a significant degree of directional dependence when side-hole microtip transducers are used, as in the present study, the orientation of the transducer could affect the values measured.

Conclusions

The TVT procedure as a second operation could provide an overall cure rate of 74% with a low complication rate in female patients with RUSI after previous failed midurethral tape procedures.     

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.     

Tension-free vaginal tape for the treatment of urodynamic stress incontinence: efficacy and adverse effects at 10-year follow-up

Background

One of the most effective and popular current procedures for the surgical treatment of stress urinary incontinence (SUI) is tension-free midurethral slings.

Objective

To evaluate the outcomes of women with retropubic tension-free vaginal tape (TVT) for urodynamic stress incontinence (USI) after 10-yr follow-up.

Design, setting, and participants

This was a prospective observational study. Consecutive women with proven USI were treated with TVT. Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded.

Intervention

Standard retropubic TVT.

Measurements

Patients underwent preoperative clinical and urodynamic evaluations. During follow-up examinations, women were assessed for subjective satisfaction and objective cure rates. Multivariable analyses were performed to investigate outcomes.

Results and limitations

A total of 63 women were included. After 10 yr, 5 patients (8%) were lost or no longer evaluable. The 10-yr subjective, objective, and urodynamic cure rates were 89.7%, 93.1%, and 91.4%, respectively. These rates were stable across the whole study period (p > 0.99). De novo overactive bladder was reported by 30.1% and 18.9% of patients at 3-mo and 10-yr follow-up, respectively (p for trend = 0.19). A total of 84.2% of women with detrusor overactivity received antimuscarinic drugs, but 43.8% were nonresponders 12 wk later. At multivariable analysis, maximum detrusor pressure during the filling phase >9 cm H₂O (hazard ratio [HR]: 16.2; p = 0.01) and maximum detrusor pressure during the voiding phase ≤29 cm H₂O (HR: 8.0; p = 0.01) were independent predictors for the recurrence of SUI, as well as obesity was for the recurrence of objective SUI (HR: 17.1; p = 0.01) and of USI (HR: 8.9; p = 0.02), respectively. Intraoperatively, bladder perforation occurred in two cases; no severe bleeding or other complications occurred.

Conclusions

The 10-yr results of this study seem to demonstrate that TVT is a highly effective option for the treatment of female SUI, recording a very high cure rate with low complications after a 10-yr follow-up.     

De novo overactive bladder following midurethral sling procedures: a systematic review of the literature and meta-analysis

Introduction and hypothesis

De novo overactive bladder (OAB) is a known complication of midurethral sling surgery for the treatment of stress urinary incontinence. To date, differences in the incidence of de novo OAB following the use of different types of midurethral sling remain relatively unknown. The purpose of the present systematic review was to evaluate this incidence and summarize current evidence.

Methods

We systematically searched the literature using the MEDLINE, Embase, Scopus, ClinicalTrials.gov, LILACS and Cochrane Central Register of Controlled Trials databases as well as the grey literature and references from the electronically retrieved articles. For comparisons of proportions, we used the chi-squared test. All reported analyses were designed as two-tailed. Statistical significance was set at p < 0.05.

Results

Finally, 32 studies were included in this systematic review, with a total of 3,139 patients who had undergone midurethral sling procedures that included transobturator tapes (TOT), retropubic tapes (TVT) or single-incision tapes (mini-slings). The overall incidence of de novo OAB was 11.5% in nonrandomized studies (280 women) and 6.4% in randomized studies (50 women). In relation to the type of midurethral sling, the incidence of de novo OAB was 9.7% for mini-slings, 11.2% for TVT-O, 8.7% for TOT and 9.8% for TVTs. The chi-squared test did not reveal significant differences (p = 0.58).

Conclusions

Current evidence suggests that the overall incidence of de novo OAB following midurethral sling procedures is approximately 9%. There is not enough evidence to support differences in the effects of the different types of sling with regard to this particular postoperative complication.

     

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.     

The Long Term (5-Years) Objective TVT Success Rate Does Not Depend on Predictive Factors at Multivariate Analysis: A Multicentre Retrospective Study

Objectives

We evaluated the predictive risk factors that could affect the long-term efficacy of the tension-free vaginal tape (TVT) procedure for the treatment of female stress urinary incontinence (SUI).

Methods

One hundred thirty-eight (mean age, 52.4 ± 9.3 yr) women who underwent the TVT procedure for SUI were selected and followed up for at least 5 yr (mean, 67.2 mo; range, 60–76) after the surgery. We analyzed the preoperative and intraoperative parameters using univariate and multivariate regression for cure rates and patients’ satisfaction.

Results

The overall 5-yr cure rate was 76.8%, with a satisfaction rate of 86.9%. The cure rates were lower in patients with high body mass index (BMI ≥ 25 kg/m²/BMI < 25 kg/m² = 68.3%:83.3%, p = 0.044), low abdominal leak point pressure (ALPP < 60 cm H₂O/ALPP ≥ 60 cm H₂O = 51.6%:82.8%, p = 0.003), and high grade of SUI (40.0% in grade III; 69.7% in grade II; 86.6% in grade I, p = 0.012). On multivariate analysis, there were no independent risk factors related to cure rate, and urgency was the only factor independently associated with patients’ satisfaction (p = 0.017; odds ratio = 4.114).

Conclusions

This study demonstrates that the TVT procedure is effective for female SUI without any independent predictive factors affecting long-term cure rate. Urgency was the only predictive factor affecting patient satisfaction. However, high BMI, low ALPP, and high grade of incontinence may impair the cure rate of the TVT.     

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.     

The anatomy of midurethral slings and dynamics of neurovascular injury

The aim of this study was to investigate the course of midurethral slings using tension-free vaginal tape. The TVT procedure was performed on six fresh pelves, measurements were obtained, and the structures were cross-referenced in 16 embalmed pelves. The midurethral sling enters the suburethral tissue 2.2–3 cm caudad to the internal urethral meatus, pierces the paraurethral musculature and vascular plexus, and exits 2±0.5 cm from the midline lateral to the point of insertion of the arcus tendineus fasciae pelvis. On the pubic tubercle the sling is 4±0.5 cm, 4±1 cm and 6±1 cm from the accessory obturator, the inferior epigastric and the external iliac vessels, respectively. The critical angle of error resulting in the external iliac vessel injury is 7–15°. A current knowledge of pelvic anatomy may help the surgeon avoid the neural and vascular structures that are in the path of the sling.Editorial Comment: The authors are to be commended for the completion of a detailed observational study further investigating the course of the TVT tunneler during placement of the sling material. An unpublished study reported by Walters et al. found similar relationships between the TVT tunneler and the surrounding pelvic vasculature. Both of these studies highlight the importance of avoiding excessive lateral deviation or rotation of the TVT tunneler during placement.The conceptualization of a dynamic pelvic anatomy in relation to the advancing tip of a midurethral sling trocar is advocated to lessen intraoperative complications.S. Abbas Shobeiri can also be reached at     

Patient satisfaction after retropubic and transobturator slings: first assessment using the Incontinence Outcome Questionnaire (IOQ)

Introduction and hypothesis

The aim of the Incontinence Outcome Questionnaire (IOQ) is to assess quality of life and patient-reported outcome after midurethral slings.

Methods

In this retrospective study, 626 patients with a minimum follow-up period of 1?year were sent the IOQ. Four hundred twenty-two of 626 (67.4%) patient responses were evaluated.

Results

The mean IOQ QoL extended score was 33.7?±?17.5 and comparable for tension-free vaginal tape (TVT), outside-in transobturator tape (TOT), and inside-out transobturator vaginal tape (TVT-O). Evaluation of IOQ question about readmission revealed a total of 32 patients (18 TVT, 12 TOT, and 2 TVT-O) who underwent a subsequent operation due to sling-related complications. Freedom from reoperation for recurrent SUI at 1, 2, and 5?years was 100%, 99.7?±?0.3%, and 99.7?±?0.3% for TVT, 100% for TVT-O, and 94.2?±?2.5%, 91.9?±?2.9%, and 89.9?±?3.5% for TOT, respectively (p?<?0.001).

Conclusions

Patient satisfaction, assessed using the IOQ, is high after retropubic and transobturator slings. In our collective, relapse incontinence is higher after TOT.     

Gender and Age Differences in the Perception of Bother and Health Care Seeking for Lower Urinary Tract Symptoms: Results from the Hospitalised and Outpatients’ Profile and Expectations Study

Background

Few comparisons have been made of health care seeking behaviour for lower urinary tract symptoms (LUTS) between men and women, as well as trends across age groups.

Objective

To investigate the bother from LUTS and effect on health care seeking in both men and women of different age groups and in comparison between the two genders.

Design, setting, and participants

A representative cross section of each of 13 clinics of a general academic hospital, with equal numbers of subjects recruited in each of six design cells that were defined by age (18–40, 41–60, 61–80 yr) and gender.

Intervention

A 2-h in-person interview, conducted by a trained psychologist/interviewer in a clinic office.

Measurements

Severity of LUTS was measured by the International Prostate Symptom Score (IPSS). Treatment seeking was measured by a single item. A bother question was modified to assess overall bother. Impact on quality of life (QoL) was measured by the IPSS QoL question.

Results and limitations

The final study sample comprised 415 patients. More women than men reported the presence of LUTS (85.5% vs 75.2%; p = 0.01). LUTS were more bothersome in women (25.4% of women vs 17.6% of men with bother “some” or “a lot”; p = 0.02). Severity of LUTS increased with age in both genders (men: p < 0.001; women: p = 0.03). Bother from LUTS increased as severity of symptoms increased in both genders (p < 0.001) but was associated with age only in men (p < 0.001). QoL showed similar results as bother. Although men and women had equal prevalence of treatment seeking (27.9% vs 23.7%; p = 0.40), men, but not women, were more likely to seek treatment as age (p < 0.01) and severity of LUTS (p < 0.001) increased. In multivariate logistic regressions, only bother from LUTS was associated with treatment seeking in women, compared with bother, age, and the presence of voiding symptoms in men.

Conclusions

In our hospital-based sample, differences in LUTS frequency, bother, and health care seeking profiles between men and women suggest a different perception and response to LUTS between the two genders.     

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.     

Is Burch or mid-urethral sling better with abdominal sacral colpopexy?

Introduction and hypothesis  This study aims to compare the post-operative rates of stress urinary incontinence (SUI) after abdominal sacral colpopexy (ASC) with either Burch or mid-urethral sling, tension-free vaginal tape (TVT), or no anti-incontinence procedure. The null hypothesis was there would be no difference in SUI among groups. Methods  A cohort of women who had undergone ASC (n = 150) either alone or with an anti-continence procedure were analyzed to determine the rates of post-operative SUI. Statistically significant differences were evaluated with a Student’s t-test. Results  A total of 150 subjects were evaluated, with 115 having SUI preoperatively. Post-operatively, 10% (15/150) of all subjects had SUI. Subjects with preoperative SUI who had a Burch were more likely to have post-operative SUI than those who had a TVT (10 versus 0, p = 0.007). Conclusions  Burch and TVT procedures improve SUI symptoms in patients undergoing ASC. Mid-urethral slings performed with ASC have lower rates of post-operative SUI. Presented at the 34th American Urogynecologic Society Meeting, September 4–6, 2008, Chicago, Illinois     

The inside-out transobturator male sling for the surgical treatment of stress urinary incontinence after radical prostatectomy: midterm results of a single-center prospective study

Background

Transobturator slings are currently promoted for the treatment of stress urinary incontinence (SUI) after radical prostatectomy (RP), but data on outcome remain limited.

Objective

To assess, at midterm, the efficacy and safety of the inside-out transobturator male sling for treating post-RP SUI and to determine factors associated with failure.

Design, setting, and participants

Prospective one-center trial involving 173 consecutive patients without detrusor overactivity, treated between 2006 and 2011 for SUI following RP.

Intervention

Placement of an inside-out transobturator sling.

Measurements

Baseline and follow-up evaluations included uroflowmetry and continence and quality-of-life (QoL) questionnaires. Cure was defined as no pad use and improvement as a number of pads per day reduced by ≥50% and two or fewer pads. Complications were recorded, and factors associated with treatment failure were evaluated.

Results and limitations

Preoperatively, 21%, 35%, and 44% of the patients were using two, three to five, and more than five pads per day, respectively. After a median follow-up of 24 mo (range: 12-60 mo), 49% were cured, 35% improved, and 16% not improved. QoL was enhanced (p < 0.001), and 72% of patients were moderately to completely satisfied with the procedure. Maximum flow rates were slightly reduced (p = 0.004); postvoid residual volumes were similar (p = 0.097). Complications were urinary retention after catheter removal (15%), perineal/scrotal hematoma (9%), pain lasting >6 mo (3%), and sling infection (2%); all were managed conservatively. Severe SUI before sling surgery was not associated with a worse outcome, whereas obesity and a history of pelvic irradiation or bladder neck stenosis were independent risk factors of failure, with risk ratios of 7.9 (95% confidence interval [CI], 3.3-18.9), 3.3 (95% CI, 1.4-7.8), and 2.6 (95% CI, 1.1-6.5), respectively.

Conclusions

The inside-out transobturator male sling is an efficient and safe treatment for post-RP SUI at midterm. Patients with prior pelvic irradiation may not be suitable candidates.