Jonathan Duckett

Predicting early voiding dysfunction after tension-free vaginal tape

Summary The purpose of this study was to determine whether early postoperative voiding dysfunction can be predicted before inserting a tension-free vaginal tape (TVT). Multiple parameters including demographic data, history of previous anti-incontinence surgery, anaesthetic type, operator experience, type of surgical procedure (TVT alone or combined with other prolapse surgery) and preoperative urodynamic studies were analysed by univariate analysis and stepwise multiple logistic regression. The data from 500 women were prospectively collected. Early voiding dysfunction occurred in 5.8% of women postoperatively. Using stepwise multiple logistic regression, voiding by other than a detrusor contraction (p = 0.02), preoperative pressure flow rate <15 ml/s (p = 0.04) and general anaesthesia (p = 0.02) were the only factors that predicted early postoperative voiding dysfunction. The point estimate relative risks were 5.6, 11.6 and 4.4 and the positive predicting values were 11.4%, 11.8% and 16.1%, respectively. Despite statistically significant associations with early voiding dysfunction, the positive predictive values of the identified factors remain low, limiting the accurate prediction of early voiding dysfunction.

The predictive value of preoperative pressure‐flow studies in the resolution of detrusor overactivity and overactive bladder after tension‐free vaginal tape insertion

To determine whether preoperative pressure‐flow studies (PFS) predict the resolution of detrusor overactivity (DO) and overactive bladder (OAB) symptoms after a tension‐free vaginal tape procedure (TVT).

Uterus conserving prolapse surgery—what is the chance of missing a malignancy?

Introduction and hypothesisRecently, there has been a move towards uterine preserving surgery in the management of pelvic organ prolapse. The negative implications of such surgery have not been delineated. This study aims to identify the risk of finding an unexpected malignancy in these cases.MethodsA database containing details of vaginal hysterectomies performed over a 10-year period was searched. Women who underwent surgery for uterine prolapse were included. Women with other indications for surgery and those who presented with symptoms relating to endometrial or cervical malignancy were excluded. As this is a non-interventional observational study, formal ethical approval was not obtained.ResultsOut of 517 women who underwent a vaginal hysterectomy for prolapse, four cases of endometrial carcinoma were identified giving an incidence of 0.8%.ConclusionsConserving a prolapsed uterus without further investigations runs the risk of missing women with endometrial malignancy.

Update on duloxetine for the management of stress urinary incontinence.

Duloxetine is a relatively balanced serotonin and noradrenaline reuptake inhibitor (SNRI), which is the first drug with widely proven efficacy to have been licensed for the medical treatment of women with stress urinary incontinence (SUI). Despite favorable results from randomized controlled trials, surgical management continues to be the mainstay of treatment for SUI. In this review we explore the pharmacology of duloxetine in the nervous system and lower urinary tract, and the evidence for its use in the management of women with urinary incontinence.

Pain after suburethral sling insertion for urinary stress incontinence

Introduction and hypothesisPain after suburethral sling insertion is an uncommon, but troublesome complication of continence surgery; in some cases it can cause significant distress and disability. It is often not recognised, poorly diagnosed and treated by gynaecologists and urologists unfamiliar with the condition.MethodsA literature review was performed and the current evidence on pain after suburethral sling insertion reviewed.ResultsThe tension-free vaginal tape–obturator (TVT-O) procedure is associated with an increased incidence of early groin pain, but this often resolves with expectant management. Chronic pain may be difficult to treat. The injection of local anaesthetic and steroid solutions may provide relief in some patients. Cognitive behavioural therapy has a place in treatment. In resistant cases, surgical excision may be needed. Retropubic slings can be removed laparoscopically or by open exploration of the Cave of Retzius. Obturator tapes may require groin exploration.ConclusionsSling removal may result in recurrent incontinence and further tissue and nerve damage. It does not always cure pain and may exacerbate the problem.

How do urogynaecologists treat failed suburethral slings? Experience from the British Society of Urogynaecology database and literature review

Midurethral urethral sling (MUS) procedures have high success and satisfaction rates. A small percentage of MUS operations will fail and most centres have limited experience of treating this outcome. The aim of this study was to review the British Society of Urogynaecology (BSUG) database for women who underwent repeat anti-incontinence surgery after failed MUS. A total of 313 repeat surgical procedures were identified. For any failed MUS, the commonest second surgical intervention was a repeat retropubic MUS and was used in 54% (170/313) of repeat procedures. Bladder neck injections were the second commonest repeat procedure (43/313 cases: 14%). TVT-Os were used as repeat surgery in 12% (38/313) and TOTs in 8% (25/313). Small numbers of colposuspensions (20/313, 6%) and Aldridge slings (6/313, 2%) were also used. A variety of different surgical treatments are used for failed MUSs. From the BSUG database review, the commonest second surgical intervention was a repeat retropubic MUS.

Clinicians' views on the NICE guideline on the management of female urinary incontinence

Summary In October 2006, the National Institute for Health and Clinical Excellence (NICE) released Guideline No. 40: The management of female urinary incontinence. The objective of this study was to investigate the opinions of members of the British Society of Urogynaecology (BSUG) regarding the recommendations contained in the guideline. A closed format questionnaire using stems taken directly from the NICE guideline was sent to all UK-based members of BSUG. There was a 64% response rate. When asked if the guidance overall reflected their current practice, 56.8% agreed/strongly agreed. In terms of changing their practice to comply fully with the guideline, 53.3% disagreed/strongly disagreed. There were two major areas of disagreement. Some 80% of respondents disagreed that preoperative cystometry was not necessary in ‘clinically pure’ stress urinary incontinence; 72% of respondents disagreed that immediate release oxybutynin should be the first-line treatment for women with an overactive bladder (OAB). A smaller proportion disagreed with the statements on the use of duloxetine. The majority of the guidance formalises current practice among gynaecologists and urogynaecologists practicing in the UK. There are significant concerns regarding some of the recommendations, and the results indicate that over half of the respondents would not change their practice to follow these recommendations.

Recurrent pelvic organ prolapse: International Urogynecological Association Research and Development Committee opinion

Introduction and hypothesisThis committee opinion paper summarizes available evidence about recurrent pelvic organ prolapse (POP) to provide guidance on management.MethodA working subcommittee from the International Urogynecological Association (IUGA) Research and Development Committee was formed. The literature regarding recurrent POP was reviewed and summarized by individual members of the subcommittee. Recommendations were graded according to the 2009 Oxford Levels of Evidence. The summary was reviewed by the Committee.ResultsThere is no agreed definition for recurrent POP and evidence in relation to its evaluation and management is limited.ConclusionThe assessment of recurrent POP should entail looking for possible reason(s) for failure, including persistent and/or new risk factors, detection of all pelvic floor defects and checking for complications of previous surgery. The management requires individual evaluation of the risks and benefits of different options and appropriate patient counseling. There is an urgent need for an agreed definition and further research into all aspects of recurrent POP.

Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion

Introduction and hypothesisPelvic floor disorders (PFD), including urinary incontinence, anal incontinence, and pelvic organ prolapse, are common and have a negative effect on the quality of life of women. Treatment is associated with morbidity and may not be totally satisfactory. Prevention of PFDs, when possible, should be a primary goal. The purpose of this paper is to summarise the current literature and give an evidence-based review of the prevention of PFDsMethodsA working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the prevention of PFDs was drafted, based on a review of the English-language literature. After evaluation by the entire IUGA R&D Committee, revisions were made. The final document represents the IUGA R&D Committee Opinion on the prevention of PFDs.ResultsThis R&D Committee Opinion reviews the literature on the prevention of PFDs and summarises the findings with evidence-based recommendations.ConclusionsPelvic floor disorders have a long latency, and may go through periods of remission, thus making causality difficult to confirm. Nevertheless, prevention strategies targeting modifiable risk factors should be incorporated into clinical practice before the absence of symptomatology.

The risk and severity of developing symptomatic palpitations when prescribed mirabegron for overactive bladder

OBJECTIVES Mirabegron is a new selective β3-adrenoreceptor agonist licensed for the treatment of overactive bladder (OAB). In clinical trials, mirabegron is well-tolerated with a low side-effect profile. There is little data available on the risks in a non-selected population. The presence of β-adrenoreceptors in cardiac and vascular tissue leads to the possibility of the development of adverse cardiovascular events. We conducted a consecutive cohort study to assess the risk of developing palpitations, the severity of the condition and to investigate any underlying risk factors that predispose patients with OAB to develop palpitations whilst taking mirabegron. STUDY DESIGN A consecutive cohort of patients with OAB was studied between February 2013 and June 2014. Patients were prescribed mirabegron 50mg daily and outcomes assessed at 6 weeks. Patients with known cardiac arrhythmias were excluded. In patients who developed palpitations, a detailed account of their symptoms and medical history were documented and a 12-lead electrocardiogram (ECG) was performed to assess heart rate, QT interval and the presence of any persisting arrhythmia was conducted. RESULTS A total of 279 patients were started on mirabegron. Eight patients (2.9%) reported palpitations whilst taking the drug. Two patients with a history of palpitations with no history of prolonged QT interval or arrhythmia on ECG developed worsening palpitations. The QTc was prolonged in two patients at 0.458 and 0.441s (QTc <420). Three patients developed chest pain or tightness. The palpitations resolved once therapy was stopped and did not result in serious adverse events such as hospitalisation. CONCLUSIONS Palpitations in an unselected population have a similar incidence to that demonstrated in previous drug trials. Palpitations may be associated with a worsening of cardiovascular dysfunction.