Christine Murray

Effectiveness of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency: a randomized controlled trial.

OBJECTIVE: To compare efficacy of transobturator tape with tension-free vaginal tape (TVT) in the treatment of stress urinary incontinence in women with intrinsic sphincter deficiency. METHODS: One hundred sixty-four women diagnosed with urodynamic stress incontinence and intrinsic sphincter deficiency with or without concomitant pelvic organ prolapse repair were randomized to receive TVT or transobturator tape. The primary outcome was the presence or absence of urodynamic stress incontinence at 6 months postoperatively. Secondary outcomes were the rate of operative complications, symptomatic stress incontinence requiring further surgery, and quality-of-life questionnaires. RESULTS: Of 180 women eligible to participate, 164 were enrolled and underwent surgery. Of the 138 patients assessed at 6 months with urodynamic studies, 14 of 67 (21%) had urodynamic stress incontinence in the TVT group compared with 32 of 71 (45%) in the transobturator tape group (P=.004), with nine women in the transobturator tape group having repeat sling surgery compared with none in the TVT group. In the intention-to-treat analysis, the incident rate difference for request of repeat surgery was 9.7% (95% confidence interval [CI] 0–19.9); repeat surgery would be requested in one of every six transobturator tape procedures compared with 1 of every 16 TVT procedures. The risk ratio of repeat surgery was 2.6 (95% CI 0.9–9.3) times higher in the transobturator tape group. CONCLUSION: Retropubic TVT is a more effective operation than the transobturator tape sling in women with urodynamic stress incontinence and intrinsic sphincter deficiency. CLINICAL TRIAL REGISTRATION: www.actr.org.au, Australian New Zealand Clinical Trials Registry, ACTRN12608000093381 LEVEL OF EVIDENCE: I

Uterine preservation or hysterectomy at sacrospinous colpopexy for uterovaginal prolapse

This study retrospectively compared 34 women who had a sacrospinous hysteropexy and 36 who had a vaginal hysterectomy and sacrospinous fixation for symptomatic uterine prolapse. All women underwent independent review and examination, with a mean follow-up of 36 months in the hysterectomy group and 26 months in the hysteropexy group. The subjective success rate was 86% in the hysterectomy group and 78% in the hysteropexy group (P = 0.70). The objective success rate was 72% and 74%, respectively (P = 1.00). The patient-determined satisfaction rate was 86% in the hysterectomy group and 85% in the hysteropexy group (P = 1.00). The operating time in the hysterectomy group was 91 minutes, compared to 59 minutes in the hysteropexy group (P<0.01). The mean intraoperative blood loss in the hysterectomy group was 402 ml, compared to 198 ml in the hysteropexy group (P<0.01). The sacrospinous hysteropexy is effective in the treatment of uterine prolapse. Vaginal hysterectomy may not be necessary in the surgical treatment of uterine prolapse.

Iliococcygeus or sacrospinous fixation for vaginal vault prolapse.

OBJECTIVE To compare iliococcygeus (prespinous) and sacrospinous fixation for vaginal vault prolapse. METHODS Between 1994 and 1998, 78 women underwent sacrospinous colpopexy and 50 underwent iliococcygeus fixation for the management of symptomatic vaginal vault prolapse. A matched case‐control study was designed to compare the two approaches. The matched variables included age, parity, body mass index, degree of vault prolapse, menopause, sexual activity, constipation, previous prolapse or continence surgery, stress incontinence, and length of review. Thirty‐six matched pairs were isolated, resulting in a study with a power of 50% to detect a 20% difference in the success rates between the two groups. RESULTS The subjective success rate for the iliococcygeus group was 91%; it was 94% for the sacrospinous group (P = .73). The objective success rate was 53% and 67% (P = .36), and the patient satisfaction with surgery was 78 of 100 and 91 of 100 (P = .01) on a visual analogue scale. The mean length of postoperative follow‐up was 21 months for the iliococcygeus group and 19 months for the sacrospinous group (P = .52). The recovery time was 54 days in the iliococcygeus group and 39 days in the sacrospinous group (P = .04). No significant difference was seen in the incidence of postoperative cystoceles or damage to the pudendal neurovascular bundle. CONCLUSION Sacrospinous and iliococcygeus fixation are equally effective procedures for vaginal vault prolapse and have similar rates of postoperative cystocele, buttock pain, and hemorrhage requiring transfusion. The sacrospinous ligament fixation should not be discarded in favor of the iliococcygeus fixation in the management of vaginal vault prolapse.

Laparoscopic suture hysteropexy for uterine prolapse

Objective Vaginal hysterectomy remains the accepted surgical treatment for women with uterine prolapse. The Manchester repair is favored in women wishing uterine preservation. Vaginal hysterectomy alone fails to address the pathologic cause of the uterine prolapse. The Manchester repair has a high failure rate and may cause difficulty sampling the cervix and uterus in the future. The laparoscopic suture hysteropexy offers physiologic repair of uterine prolapse. Method At the laparoscopic suture hysteropexy, the pouch of Douglas is closed and the uterosacral ligaments are plicated and reattached to the cervix. Results Forty-three women with symptomatic uterine prolapse were prospectively evaluated and underwent laparoscopic suture hysteropexy with a mean follow-up of 12 ± 7 months (range 6–32). The mean operating time for the laparoscopic suture hysteropexy alone was 42 ± 15 minutes (range 22–121), and the mean blood loss was less than 50 mL. On review, 35 women (81%) had no symptoms of prolapse and 34 (79%) had no objective evidence of uterine prolapse. Two women subsequently completed term pregnancies and were without prolapse. Both underwent elective cesarean delivery. Conclusion The laparoscopic suture hysteropexy is effective and safe in the management of symptomatic uterine prolapse. The result is physiologically correct, without disfiguring the cervix. This may be an appropriate procedure for women with uterine prolapse wishing uterine preservation.

Repeat Synthetic Mid Urethral Sling Procedure for Women With Recurrent Stress Urinary Incontinence

PURPOSE We reported and compared the outcomes of repeat mid urethral sling with primary mid urethral sling in women with stress urinary incontinence. MATERIALS AND METHODS A total of 1,225 consecutive women with urodynamic stress incontinence underwent a synthetic mid urethral sling procedure (955 retropubic, 270 transobturator) at our institution between 1999 and 2007. Of the patients 91% (1,112) were interviewed via telephone call with a structured questionnaire and were included in the analysis. Mean +/- SD followup was 50 +/- 24 months (range 12 to 114). A comparison between repeat (77, mean age 62 +/- 12 years) and primary (1,035, mean age 60 +/- 13 years) mid urethral sling groups was performed. Repeat sling was placed without removal of the previous sling. RESULTS The preoperative incidence of intrinsic sphincter deficiency was higher in patients who had a repeat mid urethral sling (31% vs 13%, p <0.001). The subjective stress incontinence cure rate was 86% and 62% in the primary and repeat group, respectively (p <0.001). The repeat retropubic approach was significantly more successful than the repeat transobturator approach (71% vs 48%, p = 0.04). The rates of sling related and general postoperative complications were similar between the primary and the repeat groups. However, de novo urgency (30% vs 14%, p <0.001) and de novo urge urinary incontinence (22% vs 5%, p <0.001) were more frequent in the repeat group compared with the primary group. CONCLUSIONS A repeat synthetic mid urethral sling procedure has a significantly lower cure rate than a primary mid urethral sling procedure. The repeat retropubic approach has a higher success rate than the repeat transobturator approach. The incidence of de novo urgency and urge incontinence are significantly higher in repeat procedures.

Three-year follow-up of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency.

OBJECTIVE: To compare the efficacy of tension-free vaginal tape (TVT) to transobturator tape in the treatment of women with stress urinary incontinence (SUI) and intrinsic sphincter deficiency at 3-year follow-up. METHODS: One hundred sixty-four women were randomized to either TVT or transobturator tape after diagnosis of urodynamic stress incontinence and intrinsic sphincter deficiency. Concomitant pelvic organ prolapse surgery was not an exclusion criterion. The primary outcome assessed at 3-year follow-up was symptomatic stress incontinence requiring repeat surgery. Secondary outcomes were quality-of-life parameters assessed by validated questionnaires and numerical success score. RESULTS: One hundred sixty-four women were enrolled in the study. At 3 years, 15 of the 75 (20%) women in the transobturator tape group underwent repeat surgery to correct SUI compared with one of the 72 (1.4%) in the TVT group. In other words, if TVT had been used exclusively, repeat surgery would have been avoided in one in six patients. The risk ratio of repeat surgery was 15 (95% confidence interval 2–113; P<.001) times greater in the transobturator tape group. In the transobturator tape group, the median time to repeat surgery was 15.6 months compared with 43.7 months for TVT (P<.001). The quality-of-life outcomes did show an improvement in both groups before and after surgery but no difference between the two slings in the Urogenital Distress Inventory short form, the Incontinence Impact Questionnaire short form, and a patient-rated numerical success score. CONCLUSION: The long-term cure rates for retropubic TVT are significantly greater than for transobturator tape in women with urodynamic stress incontinence and intrinsic sphincter deficiency. Urethral functions tests such as urethral closure pressure and Valsalva leak point pressures are of value in determining what surgery to perform. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, www.anzctr.org.au, ACTRN12608000093381. LEVEL OF EVIDENCE: I

Urinary and faecal incontinence following delayed primary repair of obstetric genital fistula

Objective To evaluate: (1) the factors associated with the development of obstetric genitourinary fistula, (2) the incidence of urinary and faecal incontinence following closure of the fistula and (3) the urodynamic findings in women with persistent urinary incontinence.

Sacral nerve root stimulation for lower urinary tract dysfunction: overcoming the problem of lead migration

Objective To evaluate lead migration for two different test electrodes and the response to trial stimulation of the S3 nerve root during the selection of patients for a sacral neuromodulation implant to manage lower urinary tract dysfunction.

Patients with Spina Bifida and their Caregivers Feelings about Intermittent Bladder Catheterization in Brazil and Germany: A Correlational Study.

A major complication for individuals with spina bifida (SB) is managing their neurogenic bladder. For many, this process evokes negative feelings associated with guilt, dependence, and lack of self-worth. Purpose: The aim of the study was to compare feelings that hinder the performing of intermittent bladder catheterization reported by individuals with SB and their families in two countries of different sociocultural characteristics: Brazil and Germany. Design and Methods: Quantitative and comparative study with convenience sampling. The sample comprised 200 SB patients and their caregivers, 100 from Brazil and 100 from Germany. Findings: When asked about the existence of negative feelings or ideas that may hinder the performance of key person responsible for IC, 155 (77.5%) participants did not report such feelings. On the other hand, 45 (22.5%) reported emotional difficulties; among these participants, 31 (69%) were Brazilians and 14 (31%) were Germans. Conclusions and Clinical Relevance: Although emotional factors are important to the adjustment of using IC methods for bladder management, the majority of people with SB and their caregivers seem to report no major emotional difficulties with this process. Yet a considerable group of participants did report such emotional difficulties associated with fear and shame. Knowing more about the factors associated with such negative feelings can facilitate interactions, provide mutual aid, and assist with resolution of practical concerns related to intermittent bladder catheterization.