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PubMed1998

Fascia lata suburethral sling vs. Burch retropubic urethropexy. A comparison of morbidity.

OBJECTIVE: To compare morbidity from the fascia lata sling to that from the Burch procedure. STUDY DESIGN: The charts of 64 consecutive patients undergoing the two procedures were reviewed for perioperative, immediate postoperative and delayed postoperative complications. RESULTS: Mean age was significantly older and prior surgery more common in the sling group, but parity and weight were comparable for the two groups. Operative time, estimated blood loss, change in hematocrit, incidence of transfusion, use of narcotics and hospital stay were not statistically different. Duration of catheter use was 2.2 days longer in the sling group (8.96 vs. 6.75 days, P = .387). Comparison of the sling vs. Burch, respectively, showed persistent urge incontinence in 42.8% and 40.0%, new urge incontinence in 22.2% and 16.6%, and cystotomy in 11% and 0%. CONCLUSION: The fascia lata sling procedure has morbidity comparable to that of Burch retropubic urethropexy. Urge incontinence needs to be specifically addressed preoperatively in both groups of patients.

Body Weight↗
PubMed1997

[Suburethral sling urethropexy: a vaginal approach].

Considering the poor long term results with the bladder neck suspensions, the poor results with the retropubic approach in obese or intrinsic sphincter deficiency and the complexity of the classical retropubic sling procedure, a simple vaginal sling urethropexy approach was developed. The vaginal mucosa is opened at 12 o'clock under the urethra. Dissection of the endopelvic fascia is undertaken. Polypropylene sutures are placed at the 4 corners of a free 2 x 4 cm rectus abdominis muscle flap which is suspended under the bladder neck transvaginally. Polypropylene sutures are tied at the rectus muscle through a 3 cm suprapubic incision. 25 patients were operated by one single surgeon. 7 had previous uretropexies. Previous hysterectomies: 8. Average age: 57. Average weight: 67.6. Severe stress incontinence was demonstrated in 23 patients. 9 patients had mixed incontinence. Average protective pads per day pre-op: 4.1. OR time: 93.8 min. Blood loss was minimal. 10 patients had transient post op retention (24 days average). 1 bladder perforation. 2 incisional hernias. 6 suprapubic wound infections. Average hospital stay: 5.95 days. The average follow up was 22 months. All patients were either cured (76%) or improved. 73% were satisfied (questionnaire). Despite a longer OR time, and the incidence of transient post op retention, this vaginal sling urethropexy approach is a simple and efficient procedure. It can be useful in previously operated or obese patients. It is easier to perform than the more conventional retropubic or combined (retropubic and vaginal) sling urethropexy.

Dissection↗
PubMed2005

Reasons for and treatment of surgical complications with alloplastic slings.

Suburethral slings with tension-free vaginal tapes have become a popular treatment for stress urinary incontinence. Case reports on singleton complications are numerous and of clinical interest. Four European centers for urogynecology report on 328 surgical reinterventions after tension-free slings. Poor surgical technique is the most frequent cause of problems (45%), followed by incorrect indication (38%). The most frequent symptom is functional or anatomical outlet obstruction; perforation or penetration and defect healing are rare, but, apparently more frequent than described in studies or follow-up series previously.

Humans↗
PubMed1997

Pubic bone suburethral stabilization sling for recurrent urinary incontinence.

A suburethral sling anchored to the posterior-inferior aspect of the pubic bone with bone screws placed transvaginally is described for recurrent urinary incontinence. The technique involves placing a suburethral patch of a synthetic fiber at the junction of the upper one-third and lower two-thirds of the urethra and securing it by titanium bone screws to the posterior-inferior pubis for site-specific urethral support and stabilization of normally positioned continence anatomy. The procedure was performed from August 1990 through December 1991 in 27 patients with recurrent stress urinary incontinence after previous urinary incontinence surgery, of whom 25 patients were followed yearly until August 1994. None of these 25 patients have had a recurrence as of August 1996. The initial success of the pubic bone suburethral stabilization sling merits further study for the cure of urinary incontinence in patients with a hypermobile urethra or low-pressure urethral conditions.

Bone Screws↗
PubMed1999

Pubic bone suburethral stabilization sling: laparoscopic assessment of a transvaginal operation for the treatment of stress urinary incontinence.

The objective was to examine laparoscopically the mechanism and precision of a new transvaginal method for fixation of a suburethral stabilization sling prosthesis designed for the treatment of recurrent stress urinary incontinence. Nine patients with recurrent stress urinary incontinence after previous anti-incontinence surgery underwent transvaginal placement of a pretrimmed 2.0 x 5.5 cm synthetic pubic bone suburethral stabilization sling prosthesis with pubic bone anchors. Before the sling fixation sutures were tied, the space of Retzius was opened laparoscopically with an operative laparoscope, and sling placement was assessed. Patients were followed up postoperatively at routine intervals. All nine procedures were accomplished uneventfully and as planned. Laparoscopic surveillance demonstrated that bone anchor placement by palpation was accurate and that low-tension sling fixation necessitated 2.0- to 2.5-cm suture bridges between the lateral sling edges and the pubic bone anchors in all cases. Continence was restored in all cases; two patients experienced mild, transient urinary retention; one patient experienced transient detrusor instability. No significant postoperative complications were noted. Low-tension pubic bone suburethral sling placement requires suture bridging of approximately 2.0 to 2.5 cm per side when a prosthesis 5.5 cm long is employed.

Adult↗
PubMed2002

Complications of urethral sling procedures.

PURPOSE OF REVIEW: To review the current literature on complications of suburethral slings used to treat stress urinary incontinence in the female. RECENT FINDINGS: The surgical treatment of female urinary incontinence has changed considerably since the development of the tension-free vaginal tape procedure, introduced by Ulmsten in 1995. As the follow-up for the first studies is now more than 5 years, the 'long-term' results of the technique can be evaluated. Furthermore, now that the learning phase has been completed and the technique can be considered to be well mastered, it is interesting to review the complications inherent in this technique, their frequency, including those rarer complications that are sometimes associated with severe morbidity, and to consider the ways in which these complications can be prevented or treated. The development of the tension-free vaginal tape procedure has not prevented the development of other types of suburethral sling, but on the contrary, has promoted the development of these alternatives by the use of various sling insertion techniques, and especially various types of materials. There has even been a renewed interest in materials that have been known for a long time (heterologous and autologous materials) in some recent papers, and new synthetic suburethral slings have been proposed with the objectives of combining low morbidity, safety and efficacy. SUMMARY: Monofilament polypropylene meshes can be used safely to perform suburethral slings and seems to be the most suitable material in this indication according to the existing literature.

Female↗
PubMed2004

High rate of vaginal extrusion of silicone-coated polyester sling.

OBJECTIVES: To report the results of a pilot study evaluating the suitability of silicone-coated polyester as a suburethral sling material for female stress incontinence surgery. METHODS: Ten women with stress or mixed urinary incontinence were prospectively evaluated with history and physical examination, pad test, urodynamic studies, and the Incontinence-Quality of Life questionnaire. The 2 x 7-cm sling was secured with transvaginal bone anchors placed through an anterior vaginal wall incision. Patients were evaluated at 1, 6, and 12 months by history and physical examination, pad test, and the Incontinence-Quality of Life and Success Rate and Overall Patient Satisfaction questionnaires. RESULTS: Ten patients (mean age 62.3 years) underwent successful placement of the suburethral sling. The Incontinence-Quality of Life scores improved from a mean total score of 43.3 +/- 14.6 preoperatively to 97.7 +/- 14.4 at 1 year postoperatively (P <0.001). The Success Rate and Overall Patient Satisfaction questionnaires completed at 1 year demonstrated a mean satisfaction rating of 8.9 +/- 1.7 (scale 1 to 10), and the mean reported improvement in incontinence was 90% +/- 16.3%. The mean pad weight decreased from 103.1 +/- 33.2 g preoperatively to 1.6 +/- 1.01 g at 1 year (P <0.007). Two patients (20%) developed vaginal extrusion of the suburethral sling at 6 and 10 months. The slings were removed surgically. Both women healed without incident and reported continued continence at 1 year without additional surgical intervention. CONCLUSIONS: Placement of a suburethral sling using transvaginal bone anchors and silicone-coated polyester is an effective surgical treatment for stress urinary incontinence at 1 year. The high rate of vaginal extrusion in our series limits its utility.

Coated Materials, Biocompatible↗
PubMed2004

[Functional consequences and complications of surgery for female stress urinary incontinence].

OBJECTIVE: The functional consequences and complications of surgical treatment offemale stress urinary incontinence (SUI) are not systematically reported in clinical trials. The authors present a practical review of the results of the surgical techniques most frequently used for the treatment of SUI. MATERIALS AND METHODS: An exhaustive literature search concerning the various surgical techniques for female SUI, their results, and their complications, was performed using MEDLINE (1966-2003) and the PUBMED search engine. Some papers presented by expert teams at international congresses were also included. In view of the diversity and weakness of the published results, a specific classification of the consequences of this surgery was adopted, comprising treatment failures, immediate (0 to 48 hours), early (before 6 weeks) and late (after 6 weeks) surgical complications, and impact on quality of life. RESULTS: The best long-term success rate was observed for bladder neck slings. Prolene suburethral sling is a new promising technique, with an objective cure rate of more than 80%, but the publishedfollow-up does not exceed 3 years. Immediate complications included intraoperative bleeding, retropubic haematoma, urinary tract lesions, intestinal lesions, and complications related to the operative position. Early complications consisted of infections, pubic osteomyelitis, urinary fistula, sequelae of nerve lesions, and transient postoperative urinary retention. Late complications were induced voiding disorders, including dysuria, chronic urinary retention and detrusor instability, de novo genital prolapse, sexual disorders, chronic pain, chronic urinary tract infections and complications related to the use of biomaterials, including screws, synthetic tape, and artificial urinary sphincter. The quality of life after SUI surgery, although only rarely studied, was globally and constantly improved. CONCLUSION: This review of the literature shows that no operation presents satisfactory results for all patients. Knowledge of the functional consequences and complications, although interesting, does not have any real value for the choice of a particular operation. Patient information implies mastery of all techniques and the choice of treatment must be determined case by case. This review provides a classified system of validated and detailed information, essentialfor the information of candidates for this functional surgery.

Biocompatible Materials↗
PubMed2006

Safety of a new transobturator suburethral synthetic sling (TVT-O) procedure during the training phase.

OBJECTIVE: The TVT-O (Ethicon, Somerville, NJ) is a new transobturator suburethral synthetic sling used in the treatment of female stress urinary incontinence (SUI). This study aimed to evaluate the complication rates and procedural times associated with performing this procedure during a period of transition from the retropubic tension-free vaginal tape (TVT) procedure to the transobturator TVT-O procedure. METHODS: We performed a retrospective analysis of the first 50 patients to undergo the TVT-O procedure in one gynaecologist's practice. All patients had SUI or mixed urinary incontinence. Operative times and intraoperative and perioperative complications were recorded. At the two-week and six- to eight-week postoperative reviews, a urogenital history and examination were performed. RESULTS: The only complications encountered were two cases (4%) of urinary tract infection and one case (2%) of superficial wound infection. There were no cases of postoperative voiding difficulty, hemorrhage, hematoma, persistent groin pain, or vascular or visceral injuries. The mean procedural time was 21 minutes. CONCLUSION: These preliminary results indicate that the TVT-O procedure is a safe treatment for female SUI even during the training phase. In light of the safety and the ease of transition to this technique, this finding is encouraging for surgeons who are making the transition from other surgical procedures for female SUI to the transobturator TVT-O.

Adult↗
PubMed2004

Sling procedures for urinary incontinence in women.

There are many different techniques of sling surgery for female incontinence and numerous materials are available for use as a suburethral sling. Autologous materials are associated with more success and fewer complications than cadaveric material. The objectives of this review are to identity the benefits and adverse effects of suburethral sling procedures. There is no evidence that suburethral slings are better or worse than other surgical or conservative management because no trials have addressed this comparison.

Biocompatible Materials↗
PubMed2006

Various surgical approaches to treat voiding dysfunction following anti-incontinence surgery.

OBJECTIVE: The aims of this study are to report the efficacy of retropubic urethrolysis, vaginal urethrolysis, and cutting of synthetic suburethral slings in treating postoperative voiding dysfunction that occurs after anti-incontinence surgery and to report the recurrence rate of stress urinary incontinence (SUI). METHODS: All patients from January 1996 to October 2003 who presented with voiding dysfunction following an anti-incontinence procedure and who subsequently underwent either retropubic urethrolysis, vaginal urethrolysis, or synthetic suburethral sling takedown were included in the study. Pre- and postoperative irritative symptoms (urinary frequency or urgency), obstructive symptoms (hesitancy, voiding difficulty, and incomplete emptying), and stress urinary incontinence symptoms were obtained in a standardized fashion. The Incontinence Impact Questionnaire and Urogenital Distres Invetory quality of life (QOL) questionnaires were also obtained to objectify these symptoms. Other objective postoperative analysis included simple uroflowmetry, measurement of postvoid residual (PVR), and simple or subtracted cystometry. RESULTS: Forty-four patients were included in the study (suburethral sling takedown = 14, vaginal urethrolysis = 20, and retropubic urethrolysis = 10), 77% of whom had objective follow-up. Preoperatively, 31 patients (70.5%) had irritative symptoms, 41 (93.2%) had obstructive symptoms, and 6 (13.6%) had symptoms of stress urinary incontinence (SUI), while postoperatively, these symptoms were found in 30 (68.2%), 11 (25.0%), and 18 (40.9%), respectively. Postoperatively, 6 patients (17.6%) had a PVR > 100 cc, 5 patients (14.7%) had a bladder contractions, and 16 patients (47.1%) demonstrated the sign or diagnosis of (SUI). Additionally, there was a statistically significant improvement in both QOL questionnaires. CONCLUSIONS: Various surgical approaches may be used to treat voiding dysfunction following an anti-incontinence procedure. Following a vaginal or retropubic urethrolysis or takedown of a synthetic suburethral sling, obstructive symptoms are likely to improve, irritative symptoms may remain unchanged, and almost half will develop recurrence of SUI.

Adult↗
PubMed1993

[Surgical treatment of recurrent stress incontinence: Burch versus lyodura sling operation--a prospective study].

This prospective randomised study involved 52 female patients suffering from recurrent stress urinary incontinence, objectively confirmed by means of clinical incontinence tests and urodynamic examinations. They alternatively underwent colposuspension according to Burch or suburethral sling procedure surgery. Urodynamic and sonographic examinations were carried out before and 2.5 years (i.e. within a range of 2-3) after surgery according to Burch or suburethral sling procedure. There was no significant difference between the two methods with respect to subjective and objective rate of cure, which amounted to 85% of the cases involving colposuspension and 88% of cases involving the suburethral sling procedure. Both methods resulted in a significant improvement of the depression quotient and a significant elevation of the internal urethral meatus (p < 0.05). Apart from an aggravation of urge symptoms in both groups, the patients with surgery according to Burch tended towards enterocele and rectocele in the medium range, whereas urination disorders had to be accepted in the patients operated on according to the sling procedure in the long term.

Collagen↗
PubMed1997

The use of mesh in gynecologic surgery.

The aim of this review was to compare properties of the most commonly used synthetic meshes and describe their use in gynecologic procedures. An Ovid search of the English literature from 1966 to the present was carried out, together with a hand search of Index Medicus from 1950 to 1965. Articles involving the use of mesh in surgical procedures or comparative studies of the different mechanical properties of mesh are included. Overviews from urogynecologic texts and surgical texts are also included. All studies in this review consisted of retrospective case series (21 suburethral sling articles, 15 sacrocolpopexy articles, and five pelvic sling articles). No randomized prospective trials were available. Outcome variables, including cure rates and mesh-related complications, are reviewed and compared. Conclusions show that long-term success of the suburethral sling with synthetic mesh ranges from 61% to 100%, and the success rate of the abdominal sacrocolpopexies using mesh ranges from 68% to 100%. Mesh-related complications rates are frequent, with up to a 35% removal rate and 10% sinus tract formation for suburethral slings and 9% erosion rate for sacrocolpopexy. The ideal synthetic mesh material for pelvic surgery, one that induces minimal foreign-body reaction with minimal risk of infection, rejection and erosion, has yet to be developed.

Female↗
PubMed2004

Urethral erosion of tension-free vaginal tape presenting as recurrent stress urinary incontinence.

The suburethral sling with tension-free vaginal tape (TVT) has become a popular treatment for stress urinary incontinence. Erosion of the mesh into the urethra is rare, usually presenting with hematuria, pain, voiding dysfunction or urge incontinence. A patient with stress incontinence was treated with a TVT suburethral sling. One month later, symptoms of recurrent stress incontinence developed. Cystourethroscopy revealed urethral mesh erosion. Surgical removal involved cystourethroscopic-assisted transurethral resection of the mesh, followed by vaginal dissection and periurethral withdrawal. Urethral mesh erosion should be considered in a patient who presents with atypical symptoms after being treated with a suburethral sling. It is important to obtain a detailed history and have a high clinical index of suspicion for erosion. Careful and comprehensive urethroscopy, in addition to cystoscopy, should be a mandatory part of the TVT procedure. Further study is needed to determine the optimal technique for mesh removal.

Diagnosis, Differential↗
PubMed2006

[Suburethral readjustable sling (Remeex) for the treatment of female urinary incontinence: personal surgical technique].

OBJECTIVES: Currently there is not agreement about the adequate tension for each patient with female stress urinary incontinence treated with urethral slings. The adjustable tension sling Remeex (external mechanic regulation) allows adjustment to ideal tension trying to avoid or minimize possible reoperations. The objective of these paper is to describe the components of the Remeex system, its indications, and the surgical technique to implant and adjust it. METHODS INDICATIONS: The Remeex system is indicated for female urinary incontinence in cases of urethral hypermobility, fixed urethra, primary sphincteric dysfunction, failure of other incontinence repaired techniques, and urinary incontinence in bladder hyperreflexia. STUDY PROTOCOL: The diagnosis is made with appropriate history and physical examination and completed with voiding cystourethrogram and urodynamic study, urinary tract ultrasound and, optionally, urethrocystoscopy. Remeex prosthesis characteristics: The system has three elements: polypropylene mesh, pressure tensor, and disconnection tool. TECHNIQUE: 1. Anesthesia: It maybe performed under general or spinal anesthesia. 2. Preparation and patient position. 3. Surgical technique step-by-step:--Abdominal access: 4-6 cm suprapubic incision and development of a supra- aponeurotic space to place the pressure tensor.--Vaginal access: longitudinal incision 1 cm from the urethra meatus, dissection of the vesicovaginal plane, and development of the space to place the polypropylene mesh.--Combined abdominal-vaginal access: bilateral punction with a 20 cm suture-passing needle from the abdomen to the vagina and passage of the mesh from the paraurethral espace threading its sutures in the pressure tensor system, and closure of the incisions.--Cystoscopy.--Tension adjustment and postoperative control. CONCLUSIONS: 1. It is an easy to implant system and a reproducible operation. 2. This technique avoids the morbidity of abdominal operations. 3. It allows the readjustment after surgery through a small suprapubic incision under local anesthesia. 4. Good results have been described in the short and mid-term.

Female↗
PubMed2002

Pelvic floor dysfunction management practice patterns: a survey of members of the International Urogynecological Association.

The authors report results of a survey of the practice patterns of International Urogynecological Association (IUGA) members in the management of urinary incontinence and pelvic organ prolapse. A questionnaire regarding current urogynecological clinical practice was developed by the Research and Development Committee of IUGA and mailed to all members of IUGA. Age, specialty, and geographic location factors were used for response comparisons. One hundred and fifty-two surveys (30%) were returned, 35% from North America, 51% from Europe/Australia/New Zealand, and 14% from elsewhere. The average age of respondents was 47.2 years (SD = 9.5), 89% were gynecologists and 11% were urologists. Overall, the procedures of choice for stress incontinence (SUI) were tension-free vaginal tape (TVT; 48.8%) and Burch colposuspension (44%). There were significant geographic variations noted. For SUI with low-pressure urethra/intrinsic sphincteric deficiency, TVT was used by 44.6% and suburethral sling by 32.3%. Various materials are used for suburethral slings, including autologous fascia (46.5%), Marlex mesh (27.8%) and cadaveric fascia lata (11.6%). Bulking agent injection therapy is used for ISD by 75% of respondents. Traditional reconstructive procedures are performed by the majority of respondents, including sacrospinous fixation (78%), abdominal sacrocolpopexy (77%), paravaginal repair (65%) and vaginal enterocele repair (93%); 6.5% use defecography in evaluating rectoceles and 44% use the POP-Q. Seventy-two per cent use urodynamic evaluation routinely in prolapse cases with no manifest SUI. Most IUGA members perform commonly accepted procedures for surgical therapy of urinary incontinence and genital prolapse. IUGA members do not frequently use anorectal physiology and fluoroscopic investigations to evaluate rectoceles prior to repair.

Adult↗
PubMed2005

Vaginal mesh extrusion associated with use of Mentor transobturator sling.

OBJECTIVES: To describe my experience of vaginal mesh extrusion using the monofilament polypropylene transobturator sling, the Mentor ObTape. The Mentor ObTape was the first transobturator sling developed as an alternative to the retropubic commercially available suburethral slings for providing mid-urethral support as treatment of female stress urinary incontinence. METHODS: Thirty patients underwent transobturator suburethral sling placement for anatomic stress urinary incontinence using the ObTape from October 2003 to January 2005. A retrospective chart review was performed to retrieve data on the safety, efficacy, complications, and outcomes using this product. RESULTS: Six patients (20%) to date have presented with defective vaginal healing manifested by extrusion of the sling material. Five patients required surgical removal of the sling material, and one underwent a trial of conservative management. No urethral erosions were noted. CONCLUSIONS: In my experience, the Mentor ObTape sling, which uses a nonwoven, minimally elastic, micropore, monofilament polypropylene mesh, incurs an unacceptably high rate of defective vaginal wound healing and mesh extrusion.

Aged↗
PubMed1998

[A new treatment procedure in stress urinary incontinence (SUI): suburethral prolene sling under local anesthesia].

An original technique for the treatment of USI under local anaesthesia is described. It consists of insertion of a Prolene sling under the middle part of the urethra. This sling is not placed under tension, but simply supports the suburethral region. In a series of 22 patients without prolapse requiring surgical correction and presenting USI confirmed by clinical examination, 20 were totally cured by this technique and the postoperative voiding flow rate was not decreased. This technique therefore appears to be simple, non-dysuric and effective.

Anesthesia, Local↗