Predictors of vaginal mesh exposure after midurethral sling placement: a case–control study

Introduction and hypothesis

Female stress urinary incontinence is highly prevalent, and synthetic midurethral sling placement is the most common type of anti-incontinence surgery performed in the USA. We aimed to identify risk factors associated with surgery used to treated vaginal mesh exposure after midurethral sling placement for stress urinary incontinence.

Methods

We identified women who underwent anti-incontinence procedures from January 2002 through December 2012. Patients with vaginal mesh exposure undergoing surgical repair after midurethral sling placement were compared with a control group without mesh exposure in a 1:3 ratio. Patients with ObTape sling placement (Mentor Corporation) were excluded. Logistic regression models were used to evaluate associations between clinical risk factors and vaginal mesh exposure.

Results

Overall, 2,123 patients underwent primary sling placement, with 27 (1.3 %) having vaginal mesh exposure necessitating surgical repair. Patients with mesh exposure were more likely to have undergone previous bariatric surgery (P?=?0.008), hemoglobin <13 g/dL (P?=?0.006), premenopausal status (P?=?0.008), age <50 years (P?=?0.001), and the retropubic approach to sling placement (P?=?0.03). Multivariate analysis identified these risk factors: previous bariatric surgery (odds ratio [OR], 7.0; 95 % CI, 1.1–61.4), retropubic approach (OR, 5.7; 95 % CI, 1.1–107.0), preoperative hemoglobin <13 g/dL (OR, 2.8; 95 % CI, 1.1–7.5), and premenopausal status (OR, 2.6; 95 % CI, 1.0–7.3). Among postmenopausal patients, those with mesh exposure were significantly more likely to receive preoperative estrogen therapy (OR, 12.4; 95 % CI, 2.7–57.8).

Conclusions

Previous bariatric surgery, retropubic approach, premenopausal status, and lower preoperative hemoglobin were associated with a significantly increased risk of surgery for vaginal mesh exposure after midurethral sling placement. Recognizing these factors can improve preoperative patient counseling.

     

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

Introduction and hypothesis

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

Methods

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

Results

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

Conclusions

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

     

Concurrent midurethral sling excision or lysis at the time of repeat sling for treatment of recurrent or persistent stress urinary incontinence

Introduction and hypothesis

Limited evidence guides operative technique in primary midurethral sling (MUS) lysis or excision at the time of repeat sling placement for persistent or recurrent stress urinary incontinence (SUI). Our objective is to compare subjective improvement in patients undergoing repeat MUS placement with and without concurrent primary sling lysis or removal.

Methods

This was a retrospective cohort study with a prospective survey of patients who underwent two MUS placements for SUI at a single institution from January 1996 to December 2015. After patient identification, the electronic record was queried for demographic and perioperative data. Subjects then completed the Urogenital Distress Index, (UDI-6), Incontinence Severity Index (ISI), and the Incontinence Impact Questionnaire (IIQ-7). Subjects were also asked if they would choose to undergo repeat MUS surgery again.

Results

Sixty-one patients were included. 17 out of 61 (28%) underwent concomitant primary sling lysis or excision, and 44 out of 61 (72%) did not. Fifty-seven percent (n = 35) completed the survey. Of the respondents, the median ISI score was 4 (1–8), with no difference between groups; 14 out of 35 (40%) reported the presence of bothersome urge incontinence, 11 out of 35 (31%) reported bothersome stress urinary incontinence, and 8 out of 35 (23%) reported symptoms of voiding dysfunction, with no difference between groups. 57% of patients (20 out of 35) would undergo repeat MUS placement again.

Conclusions

In a small cohort, concurrent excision of the primary sling at the time of repeat MUS did not improve subjective outcomes. Many patients reported urinary urgency and voiding symptoms, and only about half of patients would choose to undergo the surgery again if given the choice.

     

Vaginal prolapse repair with or without a midurethral sling in women with genital prolapse and occult stress urinary incontinence: a randomized trial

Introduction and hypothesis

We compared pelvic organ prolapse (POP) repair with and without midurethral sling (MUS) in women with occult stress urinary incontinence (SUI).

Methods

This was a randomized trial conducted by a consortium of 13 teaching hospitals assessing a parallel cohort of continent women with symptomatic stage II or greater POP. Women with occult SUI were randomly assigned to vaginal prolapse repair with or without MUS. Women without occult SUI received POP surgery. Main outcomes were the absence of SUI at the 12-month follow-up based on the Urogenital Distress Inventory and the need for additional treatment for SUI.

Results

We evaluated 231 women, of whom 91 randomized as follows: 43 to POP surgery with and 47 without MUS. A greater number of women in the MUS group reported absence of SUI [86 % vs. 48 %; relative risk (RR) 1.79; 95 % confidence interval (CI) 1.29–2.48]. No women in the MUS group received additional treatment for postoperative SUI; six (13 %) in the control group had a secondary MUS. Women with occult SUI reported more urinary symptoms after POP surgery and more often underwent treatment for postoperative SUI than women without occult SUI.

Conclusions

Women with occult SUI had a higher risk of reporting SUI after POP surgery compared with women without occult SUI. Adding a MUS to POP surgery reduced the risk of postoperative SUI and the need for its treatment in women with occult SUI. Of women with occult SUI undergoing POP-only surgery, 13 % needed additional MUS. We found no differences in global impression of improvement and quality of life.

     

Dynamic assessment of sling function on transperineal ultrasound: does it correlate with outcomes 1 year following surgery?

Introduction and hypothesis

To correlate dynamic assessment of sling function using 2D and 3D transperineal ultrasound with outcomes following transobturator sling surgery.

Methods

This is an unmatched case–control study of 100 patients who underwent transobturator sling surgery at our center between 2009 and 2012. Group A (n?=?50) patients had successful outcomes and group B (n?=?50) patients had suboptimal outcomes 1 year following surgery. The patients underwent 2D dynamic and 3D transperineal ultrasound. The two groups were compared with regard to the deformability of the sling on Valsalva, the concordance of urethral movement with the sling, and location of the sling.

Results

When compared with group B, group A had a significantly greater number of patients in whom the sling deformed at Valsalva (flat at rest, curving into a c-shape at Valsalva), the urethral movement was concordant with the sling and the sling had a midurethral location (p?<?0.0001). In all 17 patients in group B in whom the urethra moved in a concordant manner with the sling (34%), the sling did not deform on Valsalva maneuver and was located proximally. In all 15 patients in group A in whom the sling remained either flat or curved (30%), the urethra moved concordant with the sling and the sling was in midurethral location.

Conclusions

On 2D and 3D transperineal ultrasound, the best outcomes following transobturator sling surgery are associated with concordance of urethral movement with the sling, midurethral location, and deformability of the sling on dynamic assessment.

     

Early voiding dysfunction after midurethral sling surgery: comparison of two management approaches

Introduction and hypothesis

Early voiding dysfunction (EVD) with urinary retention (UR) is a complication of midurethral sling (MUS) surgery. Management is not standardized. Our objective was to characterize management approaches at our center, and report outcomes including resolution of UR, persistent voiding dysfunction, and recurrent stress urinary incontinence (SUI).

Methods

All women requiring catheterization for ≥7 days after MUS surgery during the period March 2014 to 2016 were eligible for inclusion in this prospective study. The management plan for each patient was decided jointly by the surgeon and the patient. Questionnaires regarding urinary symptoms were administered at enrollment, and 3 and 6 months after surgery. The timing and type of any surgical intervention were recorded.

Results

During the 2-year period, 31 women experienced EVD for ≥7 days after MUS surgery. At 6 months, complete data were available for 30 women (97%). Two management approaches were identified: “early mobilization” to loosen the MUS intact (in 10 patients), and continued catheterization with delayed sling lysis as needed (in 21 patients). In eight of the ten women in the early mobilization group, UR resolved after one intervention. Two required a second mobilization. For all women in this group, UR resolved after one or two procedures. In 11 of the 21 women in the continued catheterization group UR resolved without intervention. The other ten women in the continued catheterization group opted for sling lysis ≤6 months after MUS surgery. None of the women in the mobilization group reported SUI at 6 months in contrast to 9 of 20 (45%) in the planned continued catheterization group (p?=?0.029). Seven of the nine women experiencing recurrent SUI had undergone sling lysis.

Conclusions

Patients experiencing EVD after MUS surgery can be informed that UR will resolve in 50% with continued catheterization. Mobilization should be an option for those not comfortable with prolonged catheterization. Early intervention by mobilization may be associated with a lower risk of recurrent SUI, compared to continued catheterization and delayed sling lysis.

     

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.

     

A randomised comparison of single-incision versus traditional transobturator midurethral sling in women with stress urinary incontinence: results of a 24-month follow-up

Introduction and hypothesis

Midurethral sling procedures have become the principal surgical treatment for women with stress urinary incontinence (SUI). The 1-year results of this international trial comparing the efficacy and morbidity of a single-incision midurethral sling (SIMS; MiniArc) and a transobturator standard midurethral sling (SMUS; Monarc) showed that MiniArc is non-inferior regarding subjective cure and superior with regard to postoperative pain and recovery. The objective was to compare subjective and objective cure, morbidity and surgery-related discomfort following SIMS and transobturator SMUS up to a 24-month follow-up.

Methods

We carried out a non-blinded, randomised, controlled trial. Women with symptomatic SUI were eligible. Primary outcome was subjective cure, defined as an improvement on the Patient Global Impression of Improvement (PGI-I), at 12, 24 and 36 months. Secondary outcomes were objective cure based on the cough stress test, disease-specific quality of life questionnaires, surgical parameters and physical performance during recovery. Analysis was by intent to treat. Differences between the two groups regarding dichotomous variables were Chi-squared tested and presented as relative risks (RR) with corresponding 95 % confidence intervals.

Results

We randomised 97 women to MiniArc and 96 to Monarc. At the 24-month follow-up, subjective cure was 84 % following MiniArc and 89 % following Monarc (RR ?5; 95% CI ?0.17 to 0.06). Objective cure was 93 % following MiniArc and 94 % following Monarc (RR ?1; 95% CI ?0.10 to 0.07). Both procedures have low complication rates.

Conclusions

At the 2-year follow-up, the non-prespecified analysis of this randomised trial showed that the MiniArc, a single-incision sling, had similar subjective and similar objective cure rates, although non-inferiority to Monarc for subjective cure could not be demonstrated.

     

Prospective and randomized clinical trial comparing transobturator versus retropubic sling in terms of efficacy and safety

Introduction and hypothesis

The midurethral sling is the most commonly performed surgical procedure for stress urinary incontinence (SUI). We compared the efficacy of transobturator tape (TOT) and retropubic (RP) slings by evaluating objective and subjective cure rates at 12 months postsurgery and evaluate the impact on quality of life (QoL) and record intra- and postoperative complications.

Methods

This was a randomized, controlled, prospective, clinical trial with analysis of noninferiority. The hypothesis was that the TOT sling is not inferior to the RP sling. A total of 92 women with SUI were selected and randomized into two groups: TOT and RP slings.

Results

Eighty-one patients maintained follow-up 12 months postoperatively. In the per-protocol analysis, the objective cure rates were 100% for the RP sling and 93% for the TOT sling (p = 0.029). The subjective cure rates were 92% for the RP sling and 90% for the TOT sling (p = 0.02). Because none of the upper limits of the confidence interval (CI) were above the noninferiority margin, noninferiority of the TOT sling could be concluded. In contrast, the intention-to-treat analysis could not show that the TOT sling was not inferior to the RP sling, because the upper limit of the CI surpassed the noninferiority margin. Postoperative complications were similar for both groups, except for higher urinary retention rates in the RP group. Regarding QoL, there was a significant improvement.

Conclusions

The cure rates of the per-protocol analysis showed the noninferiority of the TOT relative to the RP sling. The RP sling group exhibited higher urinary retention. Quality of life improved significantly in both groups.

     

Change in urinary storage symptoms following treatment for female stress urinary incontinence

Introduction and hypothesis

Sling surgery is common for stress urinary incontinence (SUI). Yet many women have stress-predominant mixed urinary incontinence (MUI). The change in urgency/urge urinary incontinence (U/UUI) following treatment is not well documented. Our aim was to assess changes in U/UUI in women undergoing a sling placement for MUI and correlate this with improvement in quality of life (QOL).

Methods

This was a retrospective review of women treated for SUI with either an autologous rectus fascia pubovaginal sling (AF-PVS) or synthetic retropubic midurethral sling (MUS). Validated questionnaires—Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire–Short Form (IIQ-7), and visual analog scale (VAS) were obtained pre- and postoperatively. The independent association between change in storage symptoms and subjective cure—as defined by improved overall score on UDI-6, VAS score?≥?7, or both —were assessed using multivariate logistic regression.

Results

Nine hundred and twenty-seven women were identified for inclusion; 718 (77.5 %) had preoperative MUI, of whom 487 (67.8 %) received an MUS and 231 (32.2 %) an AF-PVS. Similar objective cure rates were noted following MUS vs. AF-PVS (78.2 % vs. 71.9 %, p?=?0.315). Subjectively, women treated with MUS experienced greater improvement in U/UUI (72.8 % vs. 57.6 %, p?=?<0.001) than AF-PVS. Multivariate analysis showed MUS patients were more than twice as likely to show subjective improvement in UDI-6 and VAS scores than the AF-PVS cohort. Postoperatively, validated questionnaires were significantly associated with storage symptom outcome.

Conclusions

Patients with U/UUI experience significant symptom improvement following treatment for MUI. QoL assessment following surgery is directly correlated with improvement in U/UUI.

     

Transobturator versus single incision slings: 1-year results of a randomized controlled trial

Introduction and Hypothesis

To compare 1-year surgical outcomes following transobturator (TO) sling placement and single incision (SI) sling placement for the treatment of stress urinary incontinence (SUI).

Methods

We performed a randomized trial at a single institution. Patients with urodynamically proven SUI were offered participation and randomized to placement of a TO sling (Monarc?) or a SI sling (MiniArc?) between 2008 and 2011. The primary outcome measure was urinary leakage during standardized cough stress test (CST). Forty subjects in each group were required to achieve 80 % power to detect an effect size of 0.25.

Results

A total of 98 patients were randomized with 49 patients in the TO group and 49 patients in the SI group. Preoperative demographics were similar between the groups (Table 1). The TO group had a significantly longer sling operative time (10.7?±?4.8 min vs. 7.8?±?4.9 min, p?<?0.001) and greater estimated blood loss (31.6?±?26.6 mL vs. 22.9?±?22.1 mL, p?=?0.02). At the 1-year follow-up, there was no difference in the primary outcome with 9 TO patients (21 %) and 12 SI patients (29 %) having a positive CST (p?=?0.5). A composite measurement of ‘failure’, defined as patient-reported SUI and a positive CST, showed no difference between the TO group (17 %) and the SI group (27 %; p?=?0.3).

Conclusions

The SI sling provides comparable objective efficacy to the TO sling at 1 year.

     

Effect of anesthesia type on perioperative outcomes with a midurethral sling

Introduction and hypothesis

There is no consensus on the most appropriate type of anesthesia for placement of a midurethral sling. Our objective was to compare intra- and perioperative outcomes for this procedure performed under general anesthesia versus monitored anesthesia care.

Methods

Retrospective cohort analysis of women undergoing outpatient placement of synthetic retropubic midurethral sling under general anesthesia (n?=?141) or monitored anesthesia care (n?=?84). Patients undergoing concomitant procedures were excluded. Primary outcome was operating room time. Secondary outcomes included surgical and recovery times, cost, discharge home with a catheter, and postoperative pain and/or nausea.

Results

In the general anesthesia group, both operating room time (mean?±?SD, 67.6?±?13.3 min vs 56.9?±?11.8 min, p?<?0.001) and recovery room time (240.0?±?69.8 min vs 190.1?±?78.3 min, p?<?0.001) were longer, whereas there was no difference in surgical time (30.0?±?8.9 min vs 29.0?±?9.7 min, p?=?0.43). Cost was significantly higher in the general anesthesia group ($4,095?±?715 vs $3,877?±?777, p?=?0.03). There was no difference in rates of bladder perforation (6.4 % vs 11.9 %, p?=?0.33). Patients who underwent general anesthesia had higher rates of discharge with a catheter (27.0 % vs 15.8 %, p?=?0.04).

Conclusion

Monitored anesthesia care may offer significant benefits over general anesthesia in women undergoing retropubic midurethral sling, including shorter operating room and recovery times, lower costs, and less voiding dysfunction in the immediate postoperative period.

     

Safety and efficacy of single-incision sling for female stress urinary incontinence: 3 years’ results

Introduction and hypothesis

The purpose of this study was to investigate the success and complication rates of single-incision sling for treating stress urinary incontinence (SUI), with a 3-year follow-up.

Methods

This study comprised 173 female patients with SUI or mixed urinary incontinence (MUI) with dominant SUI who underwent minisling procedure. All patients had positive cough stress test preoperatively; they were followed up for 3 years after surgery (1, 3, 6, 12 months, and yearly).

Results

Total follow-up was 36 months, and mean age 51 years (44–77); 128 (74 %) patients presented SUI and 45 (26 %) MUI. Objective and subjective cure and failure rates were 83.8 % (145 cases), 6.4 % (11 cases), and 9.8 % (17 cases), respectively. There were no differences in cure rates between 1 and 3 years. Mean body mass index was 28.7 (26.1–35.2), and mean operating time 7.9 min. (6.5–11.9). There were no major intraoperative complications. Eleven patients (6.4 %) had de novo urge incontinence that resolved using anticholinergic drugs; no patient had urinary retention. Vaginal mesh extrusion was reported in nine (5.2 %) patients.

Conclusions

The minisling system attained high success rates at 3 years’ follow-up. The procedure was easy to learn and has lower complication rate.

     

A randomized,nonblinded extension study of single-incision versus transobturator midurethral sling in women with stress urinary incontinence

Introduction and hypothesis

Midurethral sling procedures are the first surgical option in women undergoing surgery for stress urinary incontinence (SUI). Single-incision midurethral-slings (SIMS) were designed to provide similar efficacy to traditional midurethral slings but with reduced morbidity. In this international trial we compared the efficacy of a SIMS (MiniArc) and a transobturator standard midurethral sling (SMUS; Monarc) in the treatment of SUI in terms of subjective and objective cure rates and morbidity over a long-term follow-up.

Methods

This was a randomized controlled nonblinded extended trial with a follow-up period of 36 months. Women with symptomatic SUI were eligible. The primary outcome was subjective cure, defined as an improvement in the Patient Global Impression of Improvement (PGI-I) score. Secondary outcomes were objective cure (negative cough stress test), disease-specific quality of life, surgical parameters and morbidity. An intention to treat analysis was performed. Differences in dichotomous variables were tested using the chi-squared test. Differences in continuous variables were tested using Student’s t test or the Mann-Whitney U test. We hypothesized that MiniArc would be noninferior to Monarc concerning subjective cure.

Results

We randomized 97 women to the MiniArc group and 96 to the Monarc group. The attrition rate was 23% in the MiniArc group and 22% in the Monarc group after 3 years. At 36 months, the subjective cure rates were 86% in the MiniArc group and 87% in the Monarc group (risk difference ?0.6%, 95% CI ?12 to 11%). The objective cure rates were 89% and 88%, respectively (risk difference 1.3%, 95% CI ?9 to 11%). Both procedures were associated with low complication rates.

Conclusions

After a follow-up of 36 months, MiniArc (SIMS) is non-inferior to Monarc (SMUS) with respect to subjective and objective cure.

     

Transobturator midurethral sling: What should patients expect after surgery?

Introduction and hypothesis

Midurethral sling (MUS) surgeries are minimally invasive procedures; however, they are not free of postoperative complications. The aim of the study was to assess the occurrence of lower urinary tract symptoms (LUTS) (urgency, nocturia, frequency, splitting/spraying, hesitancy, terminal dribbling, and subjective feeling of postvoid residual) in patients suffering from stress (SUI) or mixed (MUI) urinary incontinence with a predominant SUI component before and after transobturator MUS placement.

Methods

The study group consisted of 88 women with SUI and 18 with MUI who underwent transobturator MUS. All participants were questioned with a self-developed questionnaire before and after surgery regarding the presence of LUTS.

Results

Seven days after surgery, 62 patients (58.5%) noted voiding and postmicturition symptoms, whereas 67 (63.2%) reported problems in storage. The more commonly reported LUTS at week 1 after surgery were urgency (52.8%), splitting/spraying (41.5%), and feeling of incomplete bladder emptying (34.0%). Patients perceived that splitting/spraying was the most bothersome. After 6 months, the most common LUTS reported were hesitancy (14.1%), terminal dribbling (10.4%), and splitting/spraying (9.4%). We noticed a decrease in the number of urgency episodes >2.7 times (p < 0.001) compared with baseline. After 6 months, 97 (91.5%) patients reported the lack of incontinence episodes.

Conclusions

A vast majority of patients after MUS suffer from LUTS in the early postoperative period; however, the majority of undesired symptoms resolve spontaneously within the first 6 months postsurgery.

     

Predictors of voiding dysfunction following extensive vaginal pelvic reconstructive surgery

Introduction and Hypothesis

The objective of this study was to identify the predictors of postoperative voiding dysfunction in women following extensive vaginal pelvic reconstructive surgery.

Methods

We enrolled 1,425 women who had pelvic organ prolapse of POP-Q stage III or IV and had undergone vaginal pelvic reconstructive surgery with or without transvaginal mesh insertion from January 2006 to December 2014. All subjects were required to complete a 72-h voiding diary, and the IIQ-7, UDI-6, POPDI-6 and PISQ-12 questionnaires. Urodynamic study was performed preoperatively and postoperatively.

Results

Of the 1,425 women, 54 were excluded due to incomplete data, and 1,017 of the remaining 1,371 (74.2 %) had transvaginal mesh surgery and 247 (18 %) had concurrent midurethral sling insertion. Of 380 women (27.7 %) with preoperative voiding dysfunction, 37 (9.7 %) continued to have voiding dysfunction postoperatively. Of the remaining 991 women (72.3 %) with normal preoperative voiding function, 11 (1.1 %) developed de novo voiding dysfunction postoperatively. The overall incidence of postoperative voiding dysfunction was 3.5 % (48/1,371). Those with concurrent midurethral sling insertion were at higher risk of developing voiding dysfunction postoperatively (OR 3.12, 95 % CI 1.79?–?5.46, p?<?0.001). Diabetes mellitus, preoperative detrusor pressure at maximal flow (Dmax) <10 cm H₂O and postvoid residual volume ≥200 ml were significant risk factors for the development of postoperative voiding dysfunction (OR 3.07, 1.84 and 2.15, respectively; 95 % CI 1.69?–?5.60, 1.39?–?2.91 and 1.10?–?3.21, respectively).

Conclusions

Diabetes mellitus, concurrent midurethral sling insertion, preoperative Dmax <10 cm H₂O and postvoid residual volume ≥200 ml in patients with advanced pelvic organ prolapse were risk factors for the development of postoperative voiding dysfunction after vaginal pelvic reconstructive surgery. Therefore, counseling is worthwhile before considering vaginal pelvic reconstructive surgery.

     

De novo stress urinary incontinence after pelvic organ prolapse surgery in women without occult incontinence

Introduction and hypothesis

There is a paucity of data evaluating the risk of de novo stress urinary incontinence (SUI) after surgery for pelvic organ prolapse (POP) in women with no preoperative occult SUI. We hypothesized that apical suspension procedures would have higher rates of de novo SUI.

Methods

This was a retrospective database review of women who had surgery for POP from 2003 to 2013 and developed de novo SUI at ≥6 months postoperatively. Preoperatively, all patients had a negative stress test and no evidence of occult SUI on prolapse reduction urodynamics. The primary objective was to establish the incidence of de novo SUI in women with no objective evidence of preoperative occult SUI after POP surgeries at ≥6 months.

Results

A total number of 274 patients underwent POP surgery. The overall incidence of de novo SUI was 9.9 % [95 % confidence interval (CI) 0.07–0.14]. However, the incidence of de novo SUI in those with no baseline complaint of SUI was 4.4 % (95 % CI 0.03–0.1). There was no difference in de novo SUI rates between apical [9.7 % (n?=?57)] and nonapical [10.5 %, (n?=?217] procedures (p?=?0.8482). Multivariate logistic regression identified sacrocolpopexy [adjusted odds ratio (OR) 4.54, 95 % CI 1.2–14.7] and those with a baseline complaint of SUI (adjusted OR 5.1; 95 % CI 2.2–12) as risk factors for de novo SUI.

Conclusions

The incidence of de novo SUI after surgery for POP without occult SUI was 9.9 %. We recommend counseling patients about the risk of de novo SUI and offering a staged procedure.

     

Surgery for stress urinary incontinence in Finland 1987–2009

Introduction and hypothesis

To estimate the incidence rates of stress urinary incontinence (SUI) surgery among Finnish women from 1987 to 2009 by age, and to evaluate the trends in SUI surgery.

Methods

We conducted a retrospective register-based study. All SUI procedures on adult women over age 18 years in Finland were identified from the nationwide Care Register for Health Care. Age-specific incidence rates per 1,000 women were calculated for each year. The cumulative incidence of SUI surgery was calculated.

Results

There were 38,340 procedures for SUI in 1987–2009. The overall age-adjusted incidence rate increased 2.6-fold from 0.5/1,000 women in 1987 to 1.3/1,000 in 2002, but declined thereafter by 2009 to 0.8/1,000. There was a six-fold increase in the incidence rate in the age group 60–69 years and a ten-fold increase in the age group 70–79 years from 1987 to 2002. These marked increases in operation rates coincided with the increased use of tension-free vaginal tape (TVT). In 2002, TVT accounted for 96 % of all SUI procedures. Mid-urethral slings with transobturator techniques surpassed TVT in popularity in 2007. The life-long cumulative incidence of SUI surgery was 9.9 % in 2002 and 6.3 % in 2009.

Conclusions

The incidence rates of SUI surgery increased significantly in Finland, especially among women aged 60 to 79 years. Mid-urethral slings have become the dominant procedure.

     

Patterns and timing of artificial urinary sphincter failure

Purpose

To assess population-based trends in artificial urinary sphincter (AUS) placement after prostatectomy and determine the effect of timing on device survival and complications.

Methods

We identified patients who underwent prostatectomy and AUS placement in SEER-Medicare from 2002 to 2011. We analyzed factors affecting the time of reoperation from AUS implantation and prostatectomy using multivariable Cox proportional hazard models.

Results

In total, 841 men underwent AUS placement at a median 23 months after prostatectomy. Patients who underwent reoperation (28.5%) had higher clinical stage, more likely underwent open prostatectomy, or had prior sling placement (p < 0.03). There were no differences in rates of diabetes, smoking status, prior radiation therapy, or Charlson Comorbidity Index between those requiring reoperation vs. not (all p > 0.15). Patients with AUS placement > 15 months after prostatectomy (75%) initially experienced less need for operative reinterventions. Patients with later AUS placement were significantly more likely to have received radiation therapy [22.9 vs. 3.8% (p < 0.01)]. Nonetheless, late implantation was confirmed to be protective on multivariate analysis during the first 5 years after AUS placement [HR 0.79 (95% CI 0.67–0.92); p < 0.01]. Factors independently associated with a shorter interval time until reoperation included history of radiation [HR 1.93 (95% CI 1.33–2.80); p < 0.01] and history of prior sling [HR 1.70 (95% CI 1.08–2.68); p = 0.02]. Even for patients who underwent radiation therapy, delayed AUS implantation reduced reoperative risk.

Conclusions

Late AUS implantation in the Medicare population is associated with prolonged device survival initially, while radiation and prior sling surgery predict for earlier reoperation. Patients with delayed AUS implantation experience less immediate complications. Further work is required to identify patient-specific factors which may explain variability in timing for AUS.