Alexander Gomelsky

Surgical Treatment of Female Stress Urinary Incontinence: AUA/SUFU Guideline

Purpose: Stress urinary incontinence is a common problem experienced by many women that can have a significant negative impact on the quality of life of those who suffer from the condition and potentially those friends and family members whose lives and activities may also be limited. Materials and Methods: A comprehensive search of the literature was performed by ECRI Institute. This search included articles published between January 2005 and December 2015 with an updated abstract search conducted through September 2016. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions. Results: The AUA (American Urological Association) and SUFU (Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction) have formulated an evidence‐based guideline focused on the surgical treatment of female stress urinary incontinence in both index and non‐index patients. Conclusions: The surgical options for the treatment of stress urinary incontinence continue to evolve; as such, this guideline and the associated algorithm aim to outline the currently available treatment techniques as well as the data associated with each treatment. Indeed, the Panel recognizes that this guideline will require continued literature review and updating as further knowledge regarding current and future options continues to grow.

DETERMINANTS OF FAILURE AFTER SLING SURGERY FOR FEMALE STRESS URINARY INCONTINENCE

Results: Of 728 women, 177 (24.3%) underwent autologous rectus fascia bladder neck slings, 259 (35.6%) underwent porcine dermis bladder neck slings, and 292 (40.1%) underwent polypropylene midurethral slings. The mean follow-up period for the entire cohort was 42 months. The “SUI cure” rate was 75.4% and “global cure” rate was 54.9% for the entire cohort. Of the 153 women (21%) who achieved SUI cure but not global cure, 143 (93.5%) had a SEAPI subjective composite score > 0. The reasons for failure included: emptying (43.1%), anatomy or bladder neck descent (9.2%), pad use (20.3%), and inhibition / urge incontinence (66%). A VAS < 8 was recorded in 36 (23.5%) women and 10 of these women (6.5%) failed for reasons not included in SEAPI (e.g. posterior and apical prolapse, pelvic and abdominal pain, dyspareunia, and urgency without incontinence). Despite women undergoing 3 different sling procedures differing in some demographic, urodynamic, and perioperative criteria, reasons for failure were not statistically different between sling types. A statistically significant improvement in all QOL indices was seen in “SUI cure” and failure groups, as well as “global cure” and failure groups. Interpretation of results: Although the populations of women undergoing surgery with different sling materials differed from one another, the rate of SUI resolution appears to be similar. Likewise, the incidence of postoperative urinary urge incontinence, voiding dysfunction, pad use, and bladder neck mobility are also similar. If these factors are considered, along with symptoms not accounted for by the SEAPI scale, then the true cure rate after sling surgery is more modest than originally quoted. Despite the different cure rates, women appear to have a significant improvement in their quality of life after sling surgery.

IS SLING STIFFNESS ASSOCIATED WITH POSTOPERATIVE VOIDING DYSFUNCTION? A COMPARISION OF TWO POLYPROPYLENE MIDURETHRAL SLINGS

INTRODUCTION AND OBJECTIVES: Recent modifications to midurethral slings (MUS) by some manufacturers have resulted in stiffer slings which are less resistant to deformation in vitro. The performance of these materials after implantation and the incidence of voiding dysfunction have not been fully investigated. We retrospectively report on the postoperative voiding dysfunction after two types of suprapubic (SP) and transobturator (TO) MUS: high-stiffness (Bard) and low-stiffness (AMS). METHODS: Group 1 consisted of 80 consecutive women who underwent high-stiffness MUS (40 TO, 40 SP), under a manufacturerinstitutional agreement. Group 2 consisted of the most recent 80 consecutive women who underwent an established low-stiffness MUS (40 TO, 40 SP). All procedures were performed by one surgeon using standard placement and tensioning technique. All voiding trials were performed per protocol. Postoperative voiding dysfunction was subcategorized by: asymptomatic high post void residual (PVR), positional voiding, urinary retention < 30 days, and retention requiring urethrolysis. Secondary outcomes included validated quality of life (QOL) questionnaires. RESULTS: Of 40 women undergoing high-stiffness SP sling, 17 (42.5%) women had voiding dysfunction: high PVR (5%), retention < 30 days (25%) and urethrolysis (12.5%). In comparison, 3 (7.5%) women undergoing low-stiffness SP sling had voiding dysfunction: high PVR (5%) and retention < 30 days (2.5%) (p<0.001). The incidence of voiding dysfunction was similar between high-stiffness and low-stiffness TO slings (NS). Fifteen percent of women undergoing high-stiffness TO sling had postoperative voiding dysfunction: high PVR (10%), retention <30 days (2.5%), and positional voiding (2.5%). In comparison, 12.5% of women had voiding dysfunction after low-stiffness TO sling: high PVR (5%), positional voiding (2.5%), retention < 30 days (2.5%), and urethrolysis (2.5%). Despite the differences in voiding dysfunction, QOL indices were significantly improved for all groups. CONCLUSIONS: We noted a significantly higher incidence of postoperative voiding dysfunction in women undergoing high-stiffness SP MUS, when compared with low-stiffness SP MUS. These slings may require even looser tensioning techniques than their low-stiffness counterparts. No significant difference was observed in highand lowstiffness TO slings, suggesting that this approach may be less dependent on specific tensioning technique.

PREDICTORS OF A FAILED VOIDING TRIAL AFTER SLING AND CONCOMITANT SURGERY

Hypothesis / aims of study: While discharge home with an indwelling urethral catheter was a routine practice in the past, many women are able to void soon after pubovaginal sling surgery. An indwelling catheter may be a source of perioperative infection and the prospect of discharge with a catheter may be a source of anxiety for women undergoing sling surgery. The aim of this study was to identify perioperative factors that could predict success or failure of the postoperative voiding trial.