Different sling procedures for stress urinary incontinence: A lesson from 453 patients

Several midurethral sling (MUS) procedures, such as tension-free vaginal tape (TVT), TVT obturator (TVT-O), tension-free vaginal tape SECUR (TVT-S), and pubovaginal sling (PVS), have been used for the treatment of female stress urinary incontinence (SUI); however, which method is best for a particular patient group is not known. This study aimed to identify the best rationale for choosing the optimal MUS procedure for each patient. In total, 453 consecutive female patients with SUI who were treated with MUSs in West China Hospital of Sichuan University from September 2003 to September 2011 were enrolled in this study. All the patients underwent comprehensive pre-, intra-, and postoperative evaluations, including collection of demographic information, pelvic examination, and urodynamic testing, and operation-related complications were recorded. The Incontinence Quality of Life questionnaire was also completed. Under local or general anesthesia, 105 cases were treated with TVT, 243 with TVT-O, 90 with TVT-S, and 15 with PVS. Patients with different profiles in terms of age, symptom duration, concomitant procedures, urodynamic parameters, and pelvic organ prolapse (POP) quantification score were treated successfully; the body mass index did not differ significantly among the various treatment options. The cure and improvement rates were similar among the treatment groups: 97.14% (102/105) in TVT, 100% (243/243) in TVT-O, 98.89% (89/90) in TVT-S, and 100% (15/15) in PVS. Only minor complications were experienced by the patients. In conclusion, each MUS procedure was observed to be safe and effective in different subpopulations of patients, and the results suggest that appropriate patient selection is crucial for the success of each MUS procedure.     

Stress Urinary Incontinence in Women with Neurogenic Lower Urinary Tract Dysfunction

Purpose of Review

The purpose of this review is to discuss the pathophysiology of neurogenic SUI in the female patient, examine the evidence supporting surgical and non-surgical treatment options, and outline our recommendations for the care of this population.

Recent Findings

AFPVS appears to be more efficacious than MUS for this group; however, almost all patients will require self-catheterization after surgery. MUS have a higher probability of maintaining spontaneous voiding but also care the risk mesh complications and higher failure rates. Bladder neck AUS placement may also be considered, but most studies show high reoperation rates and have only a few female subjects. In severe refractory cases of SUI or in the setting of urethral erosion, bladder neck closure has been shown to have good continence outcomes.

Summary

SUI in the setting of neurogenic lower urinary tract dysfunction is often more severe and harder to address than non-neurogenic SUI, due in part to the high rates of ISD in this population. Patients should be screened for other causes of urinary incontinence with UDS prior to any invasive interventions. AFPVS is an appropriate first-line therapy for these patients, particularly in individuals who already perform self-catheterization. Finally, in the setting of moderate to severe urethral erosion, bladder neck closure or urinary diversion should be strongly considered.

     

Patient Reported Goal Achievement Following the Midurethral Sling Procedure for Female Stress Urinary Incontinence

Objectives: Patient perspective is very important for evaluating surgical outcomes. We investigated patient reported goal achievement, overall satisfaction and objective outcome following the midurethral sling (MUS) procedure for female stress urinary incontinence (SUI). Methods: The study prospectively enrolled 88 SUI patients who underwent the MUS procedure between August 2006 and December 2006. Patient examination included medical history, physical examination and an urodynamic study prior to surgery. Before surgery, patients were shown a list and asked to nominate one goal which they most wanted to achieve with surgery (i.e., the target goal). The goals were classified as: symptom‐related, daily life‐related, personal relationship‐ and emotion‐related, and others. Before and after the surgery, patients completed a Bristol Female Lower Urinary Tract Symptom‐Short Form questionnaire. At 1 year postoperatively, patients were assessed in terms of achievement of the target goal, overall satisfaction and cure rate. Results: At the 1‐year follow‐up, overall target goals were achieved in 90.1% of patients, 82 (93.2%) patients were satisfied with the treatment, and 82 (93.2%) patients were cured. For most patients, the target goals were symptom‐related (47 patients, 53.4%). The patients whose goal achievement was less than overall goal achievement were significantly less satisfied than those who fully achieved their goal, and goal achievement was also related to objective cure. Conclusion: Achievement of patient goals was high and could be a good measure of surgical success following MUS for female SUI.     

Challenge of One‐incision Midurethral Sling for Female Stress Urinary Incontinence: Current Results

As a result of the understanding of the pathogenesis of stress urinary incontinence in females, a tension‐free vaginal tape procedure has been introduced based on integral theory and is now widely used because of its minimal invasiveness and high success rate. Modifications over the last 10 years include changes to mesh type, technique and route of insertion of sling materials. Long‐term efficacy and quality of life data of the different midurethral sling (MUS) procedures are available. However, complications, such as bladder and urethral injury, persistent groin pain, vascular and nerve injury, and voiding difficulty can occur. Recently, one‐incision MUS procedures without tape outlets have been developed to reduce surgical invasiveness and lower the risk of complications. However, few studies have reported the outcomes following one‐incision MUS procedures. The present report reviews studies of one‐incision MUS procedures to determine whether this technique can be used in the place of older techniques. It appears that while one‐incision MUS procedures may be associated with lower complication rates, success rates may also be lower, although the latest results are promising. It takes a long time for the surgeon to become an expert in performing the technique. Proper sling tension and correct surgical plane are very important. At the moment it seems that the one‐incision sling cannot replace older slings. We need to wait for and review the long‐term prospective results of the new and minimally invasive one‐incision sling for the treatment of female stress urinary incontinence.     

Defining Causes for Overactive Bladder Symptoms in Women

Objectives: The aim of the present study was to determine the causes for overactive bladder (OAB) symptoms in women visiting a urological clinic. Methods: We prospectively recruited female patients with OAB symptoms between December 2008 and February 2010. All patients were interviewed for their detailed personal and medical history. All patients completed a 3‐day frequency‐volume chart. Symptom severity was evaluated using the International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS) questionnaires. All patients underwent either conventional pressure‐flow urodynamic studies or video‐urodynamic studies. On the basis of these evaluations, patients were assigned to one of the following categories: idiopathic OAB, stress urinary incontinence (SUI)‐associated, neurogenic bladder, or bladder outlet obstruction (BOO). Results: A total of 108 female patients were recruited into the study. The mean age of the patients was 63.75 ± 14.02 years (range: 23–89). Detrusor overactivity was demonstrated in 55 patients (51%). The differential diagnosis was idiopathic OAB in 51 women (47.2%), SUI‐associated in 46 (42.6%), neurogenic bladder in 13 (12.0%) and BOO in 7 (6.5%). Conclusion: Our study suggests that the causes for OAB symptoms could be defined in half of the women visiting a urological clinic. Among them, SUI was the most common. Moreover, OAB symptoms in women might relate to BOO. Detailed history taking and sophisticated urodynamic studies are required for a substantial group of female patients with OAB symptoms to make the correct diagnosis and provide optimal therapy.     

Evaluation of Stress Predominant Urinary Incontinence

Urodynamic studies (UDS) have been used to objectively characterize a patient’s complaint of urinary incontinence. Presumably, the clinician can utilize the UDS data to guide treatment options. It is even hoped that UDS can help predict which treatments should be utilized to produce the most effective outcomes. However, is this currently the case? The Urinary Incontinence Treatment Network (UITN) has completed four large randomized clinical trials related to treatments for urinary incontinence. Two trials compared outcomes of different surgeries for stress urinary incontinence (SUI) in which standardized UDS protocols were used. Secondary analyses of these UDS data showed that UDS were neither prognostic of treatment outcomes nor correlative with severity of UI symptoms, suggesting limited utility of UDS in the evaluation and management of the uncomplicated SUI patient. A third trial was designed to answer whether a basic office examination is not noninferior to UDS in affecting SUI surgical outcomes. The results of this study are currently in press. A fourth trial examined treatment of urgency urinary incontinence (UUI). Because UDS was not part of this trial, the utility of UDS in management and treatment of UUI could not be assessed. In summary, UDS will need to undergo further refinements to increase its clinical effectiveness in the area of urinary incontinence.     

Effects of Pelvic Organ Prolapse on the Bladder

Purpose of Review

To assess how pelvic organ prolapse (POP) and treatment affect bladder function.

Recent Findings

There is significant overlap between POP and bladder symptoms, including urinary incontinence and overactive bladder. POP may result in bladder outlet obstruction (BOO) secondary to urethral kinking, which may result in overactive bladder (OAB), dysfunctional voiding, and occult or de novo stress urinary incontinence (SUI). Improvements in obstructive symptoms and dysfunctional voiding after POP surgery suggest that pelvic floor reconstruction restores pelvic floor anatomic structure and function. Furthermore, correction of anatomic structure also seems to improve OAB symptoms, although a direct causative link has yet to be established.

Summary

Pelvic floor syndromes should be interpreted as a whole. POP, OAB, urinary incontinence, BOO, and dysfunctional voiding are all part of pelvic floor syndromes, coexisting and interacting to manifest different symptoms before and after POP treatment.

     

Application of Tissue Engineering to Pelvic Organ Prolapse and Stress Urinary Incontinence

Synthetic or biological materials can be used for the surgical repair of pelvic organ prolapse (POP) or stress urinary incontinence (SUI). While non‐degradable synthetic mesh has a low failure rate, it is prone to complications such as infection and erosion, particularly in the urological/gynecological setting when subject to chronic influences of gravity and intermittent, repetitive strain. Biological materials have lower complication rates, although allografts and xenografts have a high risk of failure and the theoretical risk of infection. Autografts are used successfully for the treatment of SUI and are not associated with erosion; however, can lead to morbidity at the donor site. Tissue engineering has thus become the focus of interest in recent years as researchers seek an ideal tissue remodeling material for urogynecological repair. Herein, we review the directions of current and future research in this exciting field. Electrospun poly‐L‐lactic acid (PLA) and porcine small intestine submucosa (SIS) are two promising scaffold material candidates. Adipose‐derived stem cells (ADSCs) appear to be a suitable cell type for scaffold seeding, and cells grown on scaffolds when subjected to repetitive biaxial strain show more appropriate biomechanical properties for clinical implantation. After implantation, an appropriate level of acute inflammation is important to precipitate moderate fibrosis and encourage tissue strength. New research directions include the use of bioactive materials containing compounds that may help facilitate integration of the new tissue. More research with longer follow‐up is needed to ascertain the most successful and safe methods and materials for pelvic organ repair and SUI treatment.     

Urethral erosion following autologous rectus fascial pubovaginal sling

Urethral erosion following pubovaginal sling is a rare occurrence. When synthetic sling materials are used urethral erosion often necessitates removal of the sling and urethral reconstruction. The literature is sparse with respect to the best approach to fascial sling erosion. We report a case of a 73 year-old woman who underwent a pubovaginal sling using autologous rectus fascia for treatment of stress urinary incontinence (SUI). She developed urethral erosion following 2 weeks of clean intermittent catheterization (CIC). Visual internal urethrotomy (VIU) was performed to incise the sling and the prolene sutures were removed to eliminate any tension. The patient subsequently voided spontaneously and had resolution of her SUI. This case demonstrates that urethral erosion may occur even when fascial slings are used. Unlike synthetic slings, when autologous fascia is used, the tissue may be left in-situ. A minimally invasive approach may achieve an excellent result without the need for complex surgical repair.     

Management of Recurrent Stress Urinary Incontinence After Failed Mid-Urethral Sling Placement

Purpose of Review

Our objective is to review the current literature on recurrent stress urinary incontinence after mid-urethral sling placement, focusing on evidence-based management considerations for this complex clinical problem.

Recent Findings

Conservative, minimally invasive surgical therapies are currently available for management of persistent or recurrent SUI after a previous mid-urethral sling (MUS).

Summary

Our review of the literature does not show a clear benefit of one approach over others and emphasizes that the ideal management for these complex patients should be determined using an individualized approach with a detailed discussion of patient symptoms, past surgical history, and goals. For symptomatic patients who are surgical candidates and desire intervention, trans-urethral bulking agents, repeat retropubic (RP) MUS, or salvage autologous pubovaginal (PV) sling appear to be the most well-described management strategies.

     

Mesh for Stress Incontinence

Stress urinary incontinence (SUI) is quite common, such that about 50 % of women with urinary incontinence report SUI as their primary symptom. Once behavioral modifications and pelvic floor muscle training have failed, surgical management is the mainstay of treatment for SUI, and mid-urethral synthetic slings (MUSS) have been established as the surgical intervention of first choice. All commercially available MUSS are made from uncoated, knitted, macroporous, type 1 polypropylene mesh. With the evolution of mesh, the evolution of the surgical treatment of SUI has evolved in tandem. The popularity of MUSS has come under scrutiny with the US Food and Drug Administration (FDA’s) public health notification. While the FDA has not yet released its final recommendations on these devices, the American Urological Association has adopted position statements on the use of mesh for the surgical treatment of SUI.     

The Role of Urodynamics in Women with Stress Urinary Incontinence

Objective: To examine the role of urodynamic (UDS) investigations in women with stress urinary incontinence (SUI).Methods: Emphasis will be placed on indications for UDS assessment as well as UDS techniques and findings which apply to women with this condition. Topics such as female bladder outlet obstruction (BOO), the utility of urethral pressure (P_ure) and valsalva leak point pressure (VLPP) measurements, and the prognostic value of UDS in this patient population will also be explored.Results: Noninvasive uroflowmetry (NIF), post-void residual (PVR) measurement, filling cystometrogram (CMG), valsalva leak point pressure (VLPP) and pressure-flow studies (PFS) can provide the urologist with a wealth of information which may be used to refine treatment decisions in complex cases of female urinary incontinence. The utility of P_ure measurements in the pre- and postoperative work-up of stress incontinent women does not appear to be supported by the majority of urologic and urogynecologic studies to date.Conclusion: Prospective randomized controlled trials to evaluate the clinical efficacy, cost-effectiveness and effect on quality of life of a full pre-operative UDS assessment compared to a less invasive, more accessible basic office evaluation in different populations of women with SUI need to be conducted before any firm conclusion can be drawn regarding the superiority of one of these clinical approaches over the other.     

Treatment of severe post-prostatectomy stress urinary incontinence using AdVance sling

Severe stress urinary incontinence (SUI) is usually treated by the implant of artificial sphincter positioned around bulbar urethra. AdVance sling is a functional, non-obstructive, anti-incontinence device that showed good results especially for mild and moderate SUI. We present our experience with AdVance sling in 7 patients with severe SUI unfit for artificial sphincter. Our results, after a follow-up of more than 6 months, showed a continence rate of 28% and an improvement rate of 43%, while 2 patients did not show any benefit. The success of AdVance sling depends on the integrity of urethral sphincter and can be applied also in selected cases for the treatment of severe post-prostatectomy stress urinary incontinence.     

The Non-surgical Options for SUI—Is Any One Optimal?

There are many options for nonsurgical management of stress urinary incontinence (SUI). With the growing aging population, there is increased incontinence and need for less invasive options for SUI treatment. Conservative strategies have long been a fundamental part of treatment and may be the only management required or only management possible in some patients. Lifestyle modification, anti-incontinence devices, and pelvic floor muscle exercises benefit a significant number of patients. This may be performed, with or without the addition of vaginal weighted cones or biofeedback. Pharmacological treatment exists, yet is not considered a standard of care. This is a comprehensive review of the non-surgical treatment options for SUI.     

Bulking agents: anesthesia techniques

Bulking therapy for the minimally invasive treatment of stress urinary incontinence (SUI) may be offered to women with urodynamic SUI, wishing to avoid the complications associated with more invasive surgery, on the basis of low operative morbidity and low longterm success rates. These bulking agents may be injected by a retrograde or antegrade technique in the periurethral tissue around the bladder neck and proximal urethra. This therapy is strongly dependent on the anesthetic technique of choice; moreover its application as an outpatient procedure implies the potential for a cost-effective treatment for selected patients with SUI. In the present paper all factors affecting the choice of different types of anesthetic techniques are discussed.     

Lessons Learned from a Decade of Multicenter Cooperative Clinical Trials in Stress Urinary Incontinence

Stress urinary incontinence (SUI) is estimated to affect 12 % to 55 % of women at some point in their life. Furthermore, 15 % to 35 % of adult American women report that their quality of life is altered by urinary incontinence. In addition to the toll SUI takes on patient lives—physically, socially and psychologically—it also comes at a significant cost to health care systems. In 1999, as an initiative of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the National Institute of Child Health and Human Development (NICHD), the Urinary Incontinence Treatment Network (UITN) was born, with the primary task of developing trials to evaluate treatment of urinary incontinence in women. The purpose of this article is to review the SUI trials conducted and challenges faced, and to highlight the lessons learned from a decade of UITN work.     

Guidelines and Practice Standardization for Female Stress Urinary Incontinence (SUI)

The estimated prevalence of urinary incontinence in the middle-aged and elderly population is estimated between 30–60 % and increases with age (16). Stress urinary incontinence (SUI) defined as the leakage of urine with an increase in intra-abdominal pressure (coughing, laughing, or sneezing) accounts for at least half of all urinary incontinence. Estimates of SUI are as high as 46 % of women. Surgery for SUI is extremely common in the U.S. alone with more than 210,000 women undergoing surgical correction. As our population continues to age and obesity remains rampant, we will continue to treat more women for SUI. This article reviews the guidelines and current recommendations for the evaluation and management of women with stress incontinence. Furthermore, we provide an algorithm for which surgical option would be appropriate.     

Autologous Muscle-Derived Cells for Urinary Sphincter Regeneration: Where are we now?

Purpose of Review

Stress urinary incontinence (SUI) remains a strikingly common condition faced by women with substantial economic and quality of life impact. Embarking upon treatment for incontinence often culminates with invasive surgical procedures with recognized complication profiles. Innovative directions for SUI therapeutics are on the horizon, including the utilization of adult autologous muscle-derived cells for urinary sphincter regeneration (AMDC-USR).

Recent Findings

Current published literature presents safety and efficacy data regarding AMDC-USR injection in 80 patients at 12-month follow-up. No adverse events attributed to the cellular product were reported. Compared to lower dose groups, the higher dose groups demonstrated enhanced percentages of patients with at least 50% reduction in stress leaks and pad weight at 12-month follow-up. All dose groups had statistically significant improvement in patient-reported incontinence-specific quality of life scores at 12-month follow-up. Conclusions from the pooled analyses indicate that injection of AMDC-USR across a range of dosages appears safe. Efficacy data suggests a dose response with more patients responsive to the higher doses of AMDC-USR.

Summary

Promising technologies for utilization of autologous cellular therapies for treatment of SUI, and conceivably multiple additional indications, are approaching fruition. Multiple phase III randomized, placebo-controlled studies for AMDC-USR are ongoing to bring this regenerative option forth for the millions of patients who may ultimately benefit.

     

Evaluation and Treatment of Persistent Stress Urinary Incontinence after Male Anti-Incontinence Procedure – AUS or Sling

The two most common anti-incontinence procedures performed for postprostatectomy incontinence (PPI) are placements of the artificial urinary sphincter (AUS) and male sling. While both procedures offer high success rates, 10-30 % of patients after AUS and 20-45 % of patients after male sling require evaluation for persistent PPI. The goals of evaluation for persistent PPI should be to verify the diagnosis of stress urinary incontinence (SUI) and to assess for concurrent bladder dysfunction. If the initial procedure was an AUS, and recurrent intrinsic sphincter deficiency is diagnosed, it is vital to distinguish among mechanical failure, urethral atrophy and erosion. If a repeat sling is considered, it is necessary to verify the degree of intrinsic sphincter deficiency (ISD) and assess for persistent or recurrent proximal urethral mobility. Because of diminished urethral compliance that results from prior AUS or male sling surgery, implantation of an AUS remains the treatment of choice for persistent SUI, as it is the most reliable method of providing the circumferential urethral compression necessary for adequate coaptation even in the setting of urethral fibrosis.     

Bulking agents for stress urinary incontinence: Are they still indicated?

Injectable bulking agents have been widely available for nearly 20 years, but their role in treating stress urinary incontinence (SUI) in women is poorly defined. Although safely and easily administered in the office or outpatient setting, injectable therapy has been associated with variable rates of success. Typically, success rates approach 70%, with fewer than half of these women achieving dryness. Multiple injections may also be necessary for optimum results. Despite few comparative studies, surgery appears to be more objectively effective than injectable therapy, although improvements in quality of life are similar. In light of this information, injectables maintain an important role in the treatment of SUI in properly selected patients who have undergone detailed discussion of goals and expectations.