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PubMed1995

Simplified surgical approach to bladder outlet obstruction following pubovaginal sling.

We report a new technique of vaginal patch interposition to relieve bladder outlet obstruction after a suburethral sling procedure when the obstruction is caused by over correction of the urethrovesical angle. In this technique the sling is incised longitudinally in the midline and dissected laterally. A vaginal patch is obtained from the vaginal mucosa, then interposed and sutured between the 2 cut edges of the sling. This method is characterized by simplicity and low morbidity, while preserving the integrity of the suburethral sling to maintain continence.

Aged↗
PubMed2004

Rising awareness of the complications of synthetic slings.

PURPOSE OF REVIEW: This article will review the current literature on the complications of synthetic suburethral slings used in the treatment of stress urinary incontinence and the management of these complications. RECENT FINDINGS: Loosely applied mid-urethral synthetic slings are becoming the treatment of choice in the management of stress urinary incontinence. Despite the ease of carrying out these procedures there is still a learning curve and, whilst the current literature shows there has been a significant reduction in the complication rate in recent years with the use of modern synthetic slings, they still occur and can be a significant cause of morbidity. There has been interest in developing better imaging techniques for both establishing early diagnosis and in assisting in the treatment of complications; magnetic resonance imaging of the urethra has been one of the modalities that has been investigated. Further work is needed to predict those who are more likely to develop complications during the placement of suburethral slings; the use of urodynamic procedures has shown equivocal results. Inevitably with more experience the techniques have evolved for the management of complications, such as the treatment of urethral obstruction with transvaginal sling incision. SUMMARY: Synthetic materials for slings provide an effective and safe method for treating urinary stress incontinence in women, and have delivered improved efficacy; nevertheless, although the incidence of complications has significantly reduced in recent years, they still represent a significant and not unsubstantial morbidity.

Female↗
PubMed2000

Complications of silicone sling insertion for stress urinary incontinence.

PURPOSE: A pilot study was performed to evaluate the suitability of silicone as a substance for suburethral sling placement. Using rectus sheath for sling placement can be time-consuming and can result in increased morbidity. Adjustable synthetic materials of consistent strength are available. Silicone has previously been used successfully and was chosen for this trial. MATERIALS AND METHODS: Slings were inserted in 7 women with stress urinary incontinence. Of the patients 3 had a history of continence surgery and presented with reduced vaginal mobility, and 2 who had not previously undergone continence surgery had intrinsic sphincter deficiency. RESULTS: In all women stress urinary incontinence was subjectively cured. However, after 7 slings were inserted the study was terminated due to a high complication rate related to erosion and sinus formation in 5 slings which were removed. Complications developed immediately or up to 11 months after sling insertion. Continence was maintained in 4 of the 5 women after the slings were removed. CONCLUSIONS: Silicone is an inappropriate material for suburethral sling placement when used as described in our cases, caution should be exercised when placing silicone slings at this site.

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PubMed2002

The YAMA UroPatch sling for treatment of female stress urinary incontinence: a pilot study.

BACKGROUND AND PURPOSE: We report our initial experience using a new suburethral sling made from bovine pericardium for the treatment of urinary incontinence. To prevent rolling and curling of the sling, a unique anti-roll clip is incorporated into the UroPatch. In addition, the sling has a series of perforations that create evenly distributed tissue integration and avoid delayed seroma or hematoma formation, thereby reducing the risk of sling rejection, infection, and erosion. PATIENTS AND METHODS: Twenty-two female patients underwent suburethral sling procedures using the UroPatch. All patients demonstrated urethral hypermobility, intrinsic sphincteric deficiency, or both. Five patients had previous surgical treatment for urinary incontinence. RESULTS: All operations were completed successfully. No intraoperative or postoperative complications occurred. There was no evidence of local or systemic reaction to the UroPatch in any of the patients. With a mean follow-up of 20 months, sling rejection, erosion, or infection has not been demonstrated, and no sling required removal to date. Urinary incontinence was corrected in all but one case. CONCLUSION: The results of this pilot study suggest that the UroPatch is a promising alternative to current slings for the treatment of female urinary incontinence.

Adult↗
PubMedDate not supplied

Male perineal sling with autologous aponeurosis and bone fixation - description of a technical modification.

Post-prostatectomy urinary incontinence is an uncommon complication of adenomectomies, occurring in approximately 1% of cases and being more frequent following radical prostatectomies. There is a significant implication in the quality of life for these patients. The surgical techniques employed for its treatment are the implantation of an artificial sphincter, peri-urethral injections and suburethral slings. Considering the low efficacy of peri-urethral injections and the high cost of artificial sphincters, we present in this work a technical modification of the suburethral sling, whose preliminary results are satisfactory. The fundamental modification in this technique is due to the replacement of the synthetic material usually employed for making the sling for autologous tissue, constituted by an aponeurotic strip taken from the rectus muscle of abdomen. This modification aims to minimize risks of urethral erosion that, despite it was not described in this population due to the use of synthetic materials, is a possibility when facing the tension that is used over the bulbar urethra. In addition to such aspects the autologous aponeurosis does not have a cost except for a short prolongation of the surgical act.

Journal Article↗
PubMed1999

Pubic osteomyelitis and granuloma after bone anchor placement.

The use of bone anchors as a superior fixation for suburethral slings is becoming popular. We present a case report of pubic osteomyelitis and granuloma after bone anchor placement. A 71-year-old woman underwent placement of a vaginal wall sling using pubic bone anchors placed through a suprapubic incision. Recurrent swelling of the mons pubis required re-exploration and removal of the anchors from an infected pubic bone. When symptoms persisted over the following 10 months, the patient underwent repeat surgery and excision of a pubic bone granuloma. The use of bone anchors in suburethral sling surgery is associated with possible increase in patient morbidity, and no benefit to the patient has been shown.

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PubMed2004

Bladder neck needle suspension for urinary incontinence in women.

BACKGROUND: Bladder neck needle suspension is an operation traditionally used for moderate or severe stress urinary incontinence in women. About a third of adult women experience some urinary incontinence, and about a third of them have moderate or severe symptoms. OBJECTIVES: To determine the effects of needle suspension on stress or mixed urinary incontinence in comparison with other management options. SEARCH STRATEGY: We searched the Cochrane Incontinence Group trials register (searched 18 September 2003). The reference lists of relevant articles were also searched. SELECTION CRITERIA: Randomised or quasi-randomised trials that included needle suspension for the treatment of urinary incontinence. DATA COLLECTION AND ANALYSIS: Trials were assessed and data extracted independently by at least two reviewers. Two trial investigators provided additional information. MAIN RESULTS: Nine trials were identified which included 347 women having six different types of needle suspension procedures and 437 who received comparison interventions. Needle suspensions were more likely to fail than open abdominal retropubic suspension (higher subjective failure rate after the first year (91/313, 29% failed versus 47/297, 16% failed after open abdominal retropubic suspension: the relative risk (RR) was 2.00 (95% confidence interval (CI) 1.47 to 2.72) although the difference in peri-operative complications was not significant (17/75, 23% versus 12/77, 16%; RR 1.44, 95% CI 0.73 to 2.83): there were no significant differences for other outcome measures. This effect was seen in both women with primary incontinence and women with recurrent incontinence after failed primary operations. Needle suspensions may be as effective as anterior vaginal repair (46/128, 36% failed after needles versus 50/129, 39% after anterior repair; RR 0.93, 95% CI 0.68 to 1.26) but there was little information about morbidity. Data for comparison with suburethral slings were inconclusive because they came from a small and atypical population. No trials compared needle suspensions with conservative management, peri-urethral injections, sham or laparoscopic surgery. REVIEWERS' CONCLUSIONS: Bladder neck needle suspension surgery is probably not as good as open abdominal retropubic suspension for the treatment of primary and secondary urodynamic stress incontinence because the cure rates were lower in the trials reviewed. However, the reliability of the evidence was limited by poor quality and small trials. There was not enough information to comment on comparisons with suburethral sling operations. Although cure rates were similar after needle suspension compared with after anterior vaginal repair, the data were insufficient to be reliable and inadequate to compare morbidity.

Female↗
PubMed2002

Bladder neck needle suspension for urinary incontinence in women.

BACKGROUND: Bladder neck needle suspension is an operation traditionally used for moderate or severe stress urinary incontinence in women. About a third of adult women experience some urinary incontinence, and about a third of them have moderate or severe symptoms. OBJECTIVES: To determine the effects of needle suspension on stress or mixed urinary incontinence in comparison with other management options. SEARCH STRATEGY: We searched the Cochrane Incontinence Group specialised register and reference lists of relevant articles. Date of last search: December 2001. SELECTION CRITERIA: Randomised or quasi-randomised trials that included needle suspension for the treatment of urinary incontinence. DATA COLLECTION AND ANALYSIS: Trials were assessed and data extracted independently by at least two reviewers. One trial investigator was contacted for additional information. MAIN RESULTS: Eight trials were identified which included 327 women having six different types of needle suspension procedures and 407 who received comparison interventions. Needle suspensions were more likely to fail than open abdominal retropubic suspension (higher subjective failure rate after the first year (70/267, 26% failed vs 33/243, 14% failed after open abdominal retropubic suspension: RR 2.10, 95% CI 1.45 to 3.04) and there were more peri-operative complications (36/75, 48% vs 23/77, 30%; RR 1.51, 95% CI 1.06 to 2.15), but there were no significant differences for other outcome measures. This effect was confined to women with primary incontinence: too few women with recurrent incontinence were studied to draw conclusions about the effects of secondary operations. Needle suspensions may be as effective as anterior vaginal repair (46/128, 36% failed after needles vs 50/129, 39% after anterior repair; RR 0.93, 95% CI 0.68 to 1.26) but there was little information about morbidity. Data for comparison with suburethral slings were inconclusive because they came from a small and atypical population. No trials compared needle suspensions with conservative management, peri-urethral injections or sham or laparoscopic surgery. REVIEWER'S CONCLUSIONS: Bladder neck needle suspension surgery is probably not as good as open abdominal retropubic suspension for the treatment of primary genuine stress urinary incontinence in terms of lower cure rates and higher morbidity. However, the reliability of the evidence was limited by poor quality and small trials. There was not enough information to comment on secondary procedures or on comparisons with suburethral sling operations. Although cure rates were similar after needle suspension compared with after anterior vaginal repair, the data were insufficient to be reliable and inadequate to compare morbidity.

Female↗
PubMed2000

Anterior vaginal repair for urinary incontinence in women.

BACKGROUND: Anterior vaginal repair (anterior colporrhaphy) is an operation traditionally used for moderate or severe stress urinary incontinence in women. About a third of adult women experience urinary incontinence. OBJECTIVES: To determine the effects of anterior vaginal repair (anterior colporrhaphy) on stress or mixed urinary incontinence in comparison with other management options. SEARCH STRATEGY: We searched the Cochrane Incontinence Group's trials register, and the reference lists of relevant articles. Date of most recent search: March 1999. SELECTION CRITERIA: Randomised or quasi-randomised trials that included anterior vaginal repair for the treatment of urinary incontinence. DATA COLLECTION AND ANALYSIS: Both reviewers independently extracted data and assessed trial quality. One trial investigator was contacted for additional information. MAIN RESULTS: Five trials were identified which included 208 women having an anterior vaginal repair and 400 who received comparison interventions. A single small trial provided insufficient evidence to assess anterior repair in comparison with physical therapy. The performance of anterior repair in comparison with needle suspension appeared similar but clinically important differences could not be confidently ruled out. No trials compared anterior repair with sling or laparoscopic interventions, or compared alternative vaginal operations. Anterior repair was less effective than abdominal retropubic suspension based on patient-reported cure rates in four trials both in the short-term (failure rate within first year after anterior repair 48/198, 24% vs 30/266, 11%; RR 2.15, 95% CI 1.4 to 3.28) and long-term (80/193, 41% vs 51/261, 20%; RR 2.25, 95% CI 1.66 to 3.04). There was some evidence from one of these trials that this was reflected in fewer repeat operations for incontinence. These findings held irrespective of the co-existence of prolapse (pelvic relaxation). Although later prolapse operation appeared to be equally common after vaginal or abdominal operation there were too few data to judge this reliably. In respect of the type of abdominal retropubic suspension, most data related to comparisons of anterior repair with Burch colposuspension. The few data describing comparison of anterior repair with the Marshall-Marchetti-Krantz procedure were consistent with those for Burch colposuspension. REVIEWER'S CONCLUSIONS: There were not enough data to allow comparison of anterior vaginal repair with physical therapy or needle suspension for primary urinary stress incontinence in women. Abdominal retropubic suspension appeared to be better than anterior vaginal repair judged on subjective cure rates in four trials, even in women who had prolapse in addition to stress incontinence. The need for repeat incontinence surgery also appeared less after the abdominal operation, but this was only reported in one small trial. However, there was not enough information about post-operative complications and morbidity.

Adult↗
PubMed1995

Use of the Cobb-Ragde needle in pubovaginal sling surgery.

The use of the suburethral sling in the treatment of intrinsic sphincter deficiency has grown in popularity and acceptance. The technique of pubovaginal sling surgery with the use of the Cobb-Ragde needle is described. This method combines the familiar use of the urethropexy suspension needle with the simplicity of the transvaginal approach.

Fascia↗
PubMed2001

Mersilene mesh sling: short- and long-term clinical and urodynamic outcomes.

OBJECTIVE: We sought to determine the long-term efficacy, safety, and urodynamic effects of the Mersilene mesh suburethral sling in treating complicated forms of genuine stress incontinence. STUDY DESIGN: Two hundred women diagnosed with genuine stress incontinence, complicated by recurrence, intrinsic sphincter deficiency, or chronically increased intraabdominal pressure underwent a suburethral mesh sling procedure (Mersilene; Ethicon Inc, Somerville, NJ). They were monitored with yearly clinical examinations plus short- and long-term postoperative urodynamic evaluations; statistical analysis was carried out by use of the Friedman 2-way analysis by rank, Fischer-Freeman-Halton exact testing, analysis of variance for repeated measures, Wilcoxon, exact Mann-Whitney U test, and Bonferroni paired t test. Of 176 patients who were 5 months or more postop, 127 (72%) had preoperative and short-term postoperative urodynamic evaluations (range 5 to 23 months, mean 12.6 months). Fifty-two of 117 women who were more than 19 months postop (44%) completed preoperative and long-term postoperative urodynamic evaluations at a mean of 63 months (range 20 to 107). One hundred thirty-six of 176 patients (77%) who were more than 4 months postop had a short- and/or long- term postoperative urodynamic evaluation (range 5 to 107 months, mean 30 months). RESULTS: Objective cure rate by stress test was 93% (126 of 136 patients) at a mean of 30 months follow-up. The long-term objective cure rate was 94% (49 of 52). Subjectively, the short- and long-term cure rates were 95.3% and 90.4%, respectively. The cotton swab angle deflection decreased by a mean of 54 degrees at 1 year and 50 degrees at 5 years. Of the 10 failures, the mean preoperative cotton swab straining angle was 19.6 degrees, with 6 being < 30 degrees. Nineteen patients had a negative preoperative cotton swab angle test result (mean straining angle 15 degrees before operation, -6 degrees after operation) and a long-term cure rate of 67%. The objective cure rate in patients with positive cotton swab angle results monitored long term (mean 62 months) was 100% (41 of 41). The postvoid residual increased by a mean of 25 mL short term and 10 mL long term. Thirty-eight patients (19%) had a total of 43 complications. Seven patients (3.5%) had long-term retention. De novo detrusor instability occurred in 12 patients (8.8%), although it was cured in 6 (4.4%). Eight patients (4%) had vaginal or inguinal sling erosion and were healed after revision. Delayed healing at the vaginal sling site responded completely to estrogen cream in two (1%) patients. Five women had treatable vaginal stenosis, 5 had a local inguinal collection/infection unrelated to the mesh, and 3 required a 2-unit transfusion of packed red blood cells. One patient each had an entrapped nerve released, a cystotomy repaired, or experienced thigh numbness or groin pain. CONCLUSIONS: The suburethral Mersilene mesh sling has a very high long-term objective and subjective cure rate in the treatment of complicated forms of genuine stress incontinence. Frequent complications do occur but are remediable. The 33% failure rate among patients with a preoperative negative cotton swab angle test result and the very low cotton swab straining angle among the 7% who had sling failures further confirms the widely held belief that sling urethropexy in the absence of hypermobility lacks efficacy.

Adult↗
PubMed2003

Colpocleisis and urinary incontinence.

OBJECTIVE: The study was undertaken to review results of colpocleisis performed for advanced pelvic organ prolapse (POP) in elderly women, with attention to perioperative stress incontinence. STUDY DESIGN: We performed a retrospective chart review of all colpocleisis procedures performed July 2000 through March 2002. RESULTS: Sixty-four women with median age 78 years (68-90 years) with symptoms and signs of advanced POP underwent partial vaginectomy and colpocleisis. Concomitantly, 21 (33%) women underwent suburethral sling and 12 (19%) underwent suburethral plication procedures for treatment of stress urinary incontinence (SUI). Three patients with dementia were unable to offer subjective symptoms. One patient died in hospital from multisystem organ failure unrelated to colpocleisis. When last seen, 2 (3%) of the remaining 60 patients had some persistence of symptoms of POP. Of 30 women without preoperative symptoms of SUI, 8 had new-onset SUI symptoms after surgery. CONCLUSION: Colpocleisis is an effective method for treatment of advanced POP. Lower urinary tract evaluation and treatment remain challenging in this setting.

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PubMed2007

Presentation and management of major complications of midurethral slings: Are complications under-reported?

AIMS: Midurethral slings have become the mainstay of stress urinary incontinence (SUI) treatment due to their efficacy and low complication rates. The purpose of this study was to report the presentation and treatment of major complications from these minimally invasive treatments presented to a tertiary referral practice and to highlight a discrepancy in major complications between literature and the food and drug administration (FDA) device failure database. METHODS: From 2001 through 2005, we reviewed all cases of midurethral sling complications that presented to our institution. A literature review of all complications due to midurethral slings during the same time period was performed as was the FDA manufacturer and user facility device experience (MAUDE) database queried for self-reported complications. RESULTS: A total of 26 patients referred to UCLA with voiding dysfunction after sling placement was found to have mesh in the urethra or bladder. Treatments required a combination of urethrolysis with mesh removal, urethral reconstruction with graft, and bladder excision. These were compared to major complications reported in the world literature of <1%. The MAUDE database contained 161 major complications out of a total of 928 complications reported for suburethral slings. There was significantly more major complications reported in MAUDE than in published literature. CONCLUSIONS: Although rare, major complications of midurethral slings are more common than appear in literature. Devastating complications involving urethral and bladder perforations can present with mild urinary symptoms and thus are likely under-diagnosed and under-reported. Most of these cases need to be managed with additional reconstructive surgery.

Databases, Factual↗
PubMedDate not supplied

[Surgical therapy for stress urinary incontinence].

Stress urinary incontinence (SUI) is a common disorder among women of all ages, which compromises their quality of life. It may compromise self-esteem, restrict lifestyle, strain relationships, and may ultimately lead to social embarrassment and isolation. Therefore, SUI management does not only imply cure or improvement of SUI, but also includes psychological and social assistance to help sufferers to cope with their condition. In this regard, it is important to acknowledge the role of the patient in the selection of an appropriate treatment. Physicians and patients can choose between conservative, pharmacological, and surgical treatments. Surgical techniques for SUI have evolved over the last 150 years. Accurate diagnosis of SUI is essential before surgery is undertaken. Many surgical procedures have been employed, which can be divided into four basic types: anterior colporrhaphy, colposuspensions, suburethral sling procedures, including TVT, as well as suburethral bulking agents. This wide variety of surgical procedures indicates the lack of consensus on which procedure is best. In most continence surgery, the benefit of restoring continence often comes at the expense of instigating new symptoms or exacerbating existing lower urinary tract symptoms.

Female↗
PubMed2005

High incidence of vaginal mesh extrusion using the intravaginal slingplasty sling.

PURPOSE: The intravaginal slingplasty (IVS) is a tension-free vaginal tape variant that uses a multi-filament polypropylene tape to support the mid urethra for the treatment of female stress urinary incontinence. Numerous cases of defective vaginal wound healing have been described in the international urogynecological literature. We describe our experience of vaginal mesh extrusion using the IVS sling. MATERIALS AND METHODS: A total of 35 patients underwent suburethral sling procedures for anatomical stress urinary incontinence using the IVS system from November 2002 to September 2003. A retrospective chart review was performed to retrieve data on safety and efficacy, complications and outcomes using this product. RESULTS: Six patients (17%) to date have presented with defective vaginal healing manifested by extrusion of the sling material. Mean time to presenting symptoms was 9 months (range 2 to 15). All patients required surgical removal of the sling material. No urethral erosions were noted. CONCLUSIONS: Our experience suggests that the IVS sling system, which uses a multi-filament polypropylene suburethral mesh, incurs an unacceptably high rate of defective vaginal wound healing and mesh extrusion.

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