Current Treatment Concepts for Stress Urinary Incontinence.

Initially, stress urinary incontinence should be treated by conservative measures, such as weight reduction, hormonal substitution, physiotherapy, pelvic floor exercise and/or the use of pessaries. Incontinence surgeries are only recommended in case of unsuccessful conservative therapy. Today, tension-free suburethral sling insertions represent the gold standard of incontinence surgery yielding very good outcomes (cure rates of 80­90 %). Pelvic-floor sonography provides important information on decision of surgical methods and the management of complications. Furthermore, intra- or paraurethral injection of bulking agents is a promising, minimally invasive surgical alternative. This article discusses treatment concepts, pre-, intra- and post-operative examinations, decision on surgical methods, operational details for surgical success, and the prevention and management of complications.

Role of intrinsic sphincter deficiency with and without urethral hypomobility on the outcome of tape insertion.

AIMS: Intrinsic sphincter deficiency (ISD) is a known risk factor for therapy failure after tension-free vaginal tape (TVT) insertion. The purpose of this study was to investigate if the severity of ISD alone or other factors such as urethral mobility and tape localization influence outcomes. METHODS: One hundred and nine women with urodynamically determined ISD, a TVT insertion, and a 6-month follow-up visit were included. Urethral length, mobility, and tape localization were evaluated by pelvic floor sonography. Patients were classified into three urethral mobility groups (hypomobile, normomobile, hypermobile). Surgical outcome was assessed by a combination of objective and subjective criteria. RESULTS: Therapeutic success rate after TVT insertion was 81.6%. The severity of ISD did not associate with therapy failure. But urethral mobility (P < 0.0001), relative tape position (P = 0.0003), and tape-urethra distance (P < 0.0001) differed between cured and not cured patient groups. Patients with a relative tape position toward 1/2 of urethral length had a higher cure rate. Significantly different cure rates (P = 0.0003) were found for hypomobile (67%), normomobile (76%), and hypermobile (100%) urethras. For ISD patients with a hypomobile urethra, highest cure rates were obtained for tape-urethra distances between 2.5 and 3.5 mm. CONCLUSIONS: The reduced cure rate for ISD patients was due to the subgroup with a hypomobile urethra. A prospective study is needed to confirm that slightly shorter tape-urethra distances and a relative tape position more toward the mid-urethra will lead to better outcomes for this patient group.

Urethral bulking for recurrent stress urinary incontinence after midurethral sling failure.

AIMS: To assess the effectiveness of a polyacrylamide hydrogel (PAHG; Bulkamid®) in treating recurrent stress urinary incontinence (SUI) following a previous midurethral sling (MUS) implant. METHODS: This observational study, conducted since 2009, included 60 patients with recurrent SUI or mixed urinary incontinence (MUI) after a previous MUS and who chose to be treated with PAHG. Objective and subjective outcomes were assessed at 1, 6, and 12 months after the initial injection. Patients were classified as cured based on a negative cough test (supine and standing) and <2 g urine on 1-hr pad test and a VAS score improved by ≥90%. Improved were those with the loss of only a few drops of urine during the cough test and 2-10 g urine on 1-hr pad test or a reduction >50% compared with preoperative urine loss and a VAS score improved by ≥75%. RESULTS: The volume of PAHG injected in the current study ranged from 1-3 ml. Cured/improved rates were 93.3% (56/60), 88.3% (53/60), and 83.6% (46/55) at 1, 6, and 12 months, respectively. Patients with MUI had a cured urgency urinary incontinence rate of 36.8%, 47.4%, and 38.9%, respectively. Voiding dysfunction rates were 13.3% (8/60), 8.3% (5/60), and 1.8% (1/55) at 1, 6, and 12 months and urinary tract infection rates were 5% (3/60), 11.7% (7/60), and 3.6% (2/55), respectively. Other adverse events were short-term and/or observed in <4% of patients. CONCLUSIONS: PAHG can be used to treat recurrent SUI after MUS failure with good outcome and low complication rates. Neurourol. Urodynam. 36:722-726, 2017. © 2016 The Authors. Neurourology and Urodynamics published by Wiley Periodicals, Inc.

Do different vaginal tapes need different suburethral incisions? The one-half rule.

AIM: Despite a wide array of vaginal tapes to treat stress urinary incontinence (SUI), evidence suggesting that both patient characteristics and tape positioning influence outcomes, and differing tape insertion pathways (retropubic vs. transobturator), it remains unclear if the same incision location is effective for all tapes. The aim of the study was to compare outcomes using two different surgical incision locations when inserting a transobturator vaginal tape (TOT) to treat SUI. METHODS: We compared patient characteristics, tape positioning, and surgical outcomes in 123 women undergoing a TOT procedure who were randomly assigned to have the surgical incision begin at 1/3 of the sonographically-measured urethral length (similar to the traditional retropubic approach) or 1/2 of the urethral length. RESULTS: It was feasible to place the tape according to intention in 99.2% of the study cohort. The overall cure rate was higher when the incision site began at 1/2 the urethral length (83.6%) than 1/3 (62.9%) (P = 0.01). In the subgroup analyses, only patients with normal urethral mobility had significantly different cure rates (85.7% vs. 55.2%, P = 0.02). No significant differences in cure rates were observed between the other mobility categories of the study groups-hypermobility was consistently associated with high cure rates and hypomobility with low cure rates. CONCLUSIONS: When surgically treating SUI with a TOT, incision at the mid-urethra using the 1/2 rule is recommended as it leads to better outcomes for most patients, particularly those with normal urethral mobility.

Ultrasound and early tape mobilization--a practical solution for treating postoperative voiding dysfunction.

AIMS: This study assessed the effectiveness of ultrasound in determining tape distance to urethra and the impact of early tape mobilization on outcomes in women with postoperative voiding dysfunction resulting from a too tightly positioned tension-free vaginal tape (TVT). METHODS: A prospective observational study was conducted with women experiencing voiding dysfunction caused by too tightly positioned tapes. Ultrasound was used to identify the cause of the dysfunction and measure the distance between tape and longitudinal smooth muscle layer (LSM) of the urethra. If the tape was too close to the LSM (<3 mm) and the residual volume was >100 ml, it was mobilized under local/analgosedation shortly after the initial TVT procedure. RESULTS: Seventy-one postoperative TVT mobilization procedures were conducted on 61 women, which was 4.1% (61/1501) of all suburethral tape procedures performed. Early tape mobilization restored normal micturition in 59 (96.7%) of the women at the time of discharge. Significant differences were found in residual volumes (P < 0.001) and tape-LSM distances (P < 0.001) pre- and post-mobilization. At 6-month follow-up visits, 58 (95.1%) women were cured of SUI, three were incontinent, and no additional voiding dysfunction occurred. CONCLUSIONS: Immediate postoperative ultrasound can reliably detect too tightly positioned tapes that can be promptly treated with tape mobilization, a short and safe procedure that does not compromise the outcome of the original procedure.

Midurethral sling incision: indications and outcomes.

INTRODUCTION AND HYPOTHESIS: Controversy continues over the effectiveness of sling incision, which is the most common operative approach to treating complications following suburethral sling insertion. This retrospective analysis assessed the indications for sling incision and patient outcomes regarding resolution of complications and stress urinary incontinence. METHODS: A review was conducted of the medical records of women who underwent sling incision between 2003 and 2010. Data such as surgical indications, ultrasound findings and medical outcomes were extracted from 198 records, and descriptive and inferential statistical methods of analysis were used. RESULTS: In the 198 patients eligible for study inclusion, the primary reasons for sling incision were overactive bladder (68 %), voiding dysfunction (61 %), and recurrent urinary tract infections (53 %). Additional complications included dyspareunia (18 %), chronic pelvic pain (17 %), and sling exposure (15 %). Sling incision led to immediate postoperative cure of voiding dysfunction in 97 % of patients. Cure rates for overactive bladder and dyspareunia were 60 % and 94 % respectively. Chronic pelvic pain was resolved in 82 % of cases and all cases of sling exposure were cured. Eighty-five (61 %) of the 140 patients who were continent before sling incision developed recurrent stress urinary incontinence (SUI) postoperatively. CONCLUSIONS: These findings indicate that sling incision can be highly successful in improving voiding dysfunction and dyspareunia, and moderately successful in curing overactive bladder and chronic pain. However, SUI may recur in more than 60 % of the patients undergoing sling incision. Consequently, patients being considered for a sling incision procedure should be informed about this possible complication.

Tape functionality: position, change in shape, and outcome after TVT procedure--mid-term results.

INTRODUCTION AND HYPOTHESIS: This study evaluates the relevance of the tape position and change in shape (tape functionality) under in vivo conditions for mid-term outcome. METHODS: Changes in the sonographic tension-free vaginal tape (TVT) position relative to the percentage urethral length and the tape-urethra distance were determined after 6 and 48 months in 41 women with stress urinary incontinence. RESULTS: At 48 months, 76% (31/41) of women were cured, 17% (7/41) were improved, and 7% (3/41) were failures. Disturbed bladder voiding was present in 12% (5/41), de novo urge incontinence in 7% (3/41). The median TVT position was at 63% of urethral length. Median tape-urethra distance was 2.7 mm, ranging from 2.9 mm in continent patients without complications to 1.1 mm in those with obstructive complications. Patients with postoperative urine loss had a median distance of 3.9 mm. The tape was stretched at rest and C-shaped during straining in 15 of 41 women (37%) at 48 months (all continent). Patients with this tape functionality at 6 months were also cured at 48 months in 86% of cases (19/22), and only 14% (3/22) showed recurrent incontinence. CONCLUSIONS: Mid-term data suggest an optimal outcome if the tape is positioned at least 2 mm from the urethra at the junction of the middle and distal thirds. Patients with optimal tape functionality at 6 months are likely to show mid-term therapeutic success.

Tape functionality: sonographic tape characteristics and outcome after TVT incontinence surgery.

AIM: To investigate tension-free vaginal tape (TVT) position and shape using ultrasound (US) and correlate the findings to outcome. MATERIAL AND METHODS: The results of TVT surgery were investigated in 72 women with urodynamic stress urinary incontinence. The main outcome parameters were US tape position in relation to the urethra and dynamic changes in TVT shape at rest and during straining. RESULTS: Sixty-two patients (86%) were continent, 6 (8%) significantly improved, and the operation failed in four cases (6%). The median tape position was at 66% of the urethral length measured by US. The median tape-urethra-lumen distance was 3.8 mm at rest. Tape placement in the upper or lower quarter of the urethra was associated with a higher failure rate. Tapes positioned less than 3 mm from the urethra significantly increased postoperative complications (P < 0.0001). The tape was flat at rest and curved during straining in 44 (61%) patients; 98% (43/44) of these women were continent after surgery. An unchanged tape shape was associated with a poorer outcome (P = 0.00038). Patients with a flat tape at rest and during straining failed in 25% and patients with a permanent curved shape in 10%. CONCLUSIONS: TVT position relative to the patient's urethra seems to play a role in treatment outcome. Outcome was best in patients with dynamic change in tape shape during straining and location of the tape at the junction between the lower and middle urethra and at least 3 mm from the urethral lumen.