R. Marijn Houwert

Risk factors for failure of retropubic and transobturator midurethral slings

OBJECTIVEnThe aim of our study was to identify and compare risk factors for failure of retropubic and transobturator procedures.nnnSTUDY DESIGNnThis was a retrospective cohort study. Women with predominant stress urinary incontinence who underwent a retropubic (n = 214) or transobturator tape procedure (n = 173) were included. Therapy was considered to have failed in women reporting any amount of urine leakage during stress after 2 and/or 12 months.nnnRESULTSnRisk factors for failure were mixed urinary incontinence (MUI; odds ratio [OR], 3.7; 95% confidence interval [CI], 1.5-9.1) and the observation of detrusor overactivity (DO) at urodynamics (OR, 8.6; 95% CI, 1.9-39.4) in the retropubic group. Reporting a history of previous incontinence surgery (OR, 3.9; 95% CI, 1.3-11.7) and a low mean urethral closure pressure (MUCP) at urodynamics (OR, 14.5; 95% CI, 1.5-139.0) were risk factors for failure in the transobturator group.nnnCONCLUSIONnWomen with previous incontinence surgery or a low MUCP might benefit more from a retropubic sling, whereas a transobturator procedure might be preferable in women with MUI or DO.

Predictive value of urodynamics on outcome after midurethral sling surgery for female stress urinary incontinence

OBJECTIVEnThe aim of this study was to evaluate the value of urodynamic investigation in the preoperative workup of midurethral sling surgery and to identify risk factors for failure after 3 different midurethral sling procedures.nnnSTUDY DESIGNnRetrospective cohort study. 437 women who underwent a tension-free vaginal tape, Monarc, or tension-free vaginal tape-obturator procedure without other simultaneously performed urogynecological surgery were included. Preoperative data were collected from the medical files. Patients who reported any amount of leakage were considered failures. The mean follow-up of the study population was 14 months.nnnRESULTSnAfter multivariate analysis, mixed urinary incontinence (P = .04), previous incontinence surgery (P = .022), and detrusor overactivity (P = .02) were significantly related to failure of midurethral sling procedures. There were no predictive urodynamic parameters for failure in patients with mixed urinary incontinence or previous incontinence surgery.nnnCONCLUSIONnThe standard use of urodynamic investigation in the preoperative workup of midurethral sling surgery needs to be revisited.

TVT-O versus Monarc after a 2–4-year follow-up: a prospective comparative study

Introduction and hypothesisThe aim of this study was to compare outcome and quality of life of tension-free vaginal tape “inside-out” (TVT-O) and Monarc transobturator tapes after 2–4xa0years.MethodsThe method used was a prospective comparative study. Participants (nu2009=u2009191) were assigned to either a TVT-O (nu2009=u200993) or a Monarc (nu2009=u200998) procedure. Cure of stress urinary incontinence (SUI) was defined as the statement of the woman of not experiencing any loss of urine upon physical exercise.ResultsCure rates after 2–4xa0years were 72% for TVT-O and 65% for Monarc, while improvement was observed in, respectively, 12% and 21% (pu2009=u20090.3). There was a statistically significant improvement in quality of life but no differences were found between both procedures.ConclusionsAfter a 2–4-year follow-up period, both procedures were equally safe and effective in curing SUI.

Outcome and complications of retropubic and transobturator midurethral slings translated into surgical therapeutic indices

OBJECTIVEnWe sought to determine and compare surgical therapeutic indices (STIs) of the retropubic tension-free vaginal tape (TVT) and 2 kinds of transobturator tape (TOT), Monarc (American Medical Systems, Minneapolis, MN), and tension-free vaginal tape obturator.nnnSTUDY DESIGNnThis was a retrospective cohort study. Patients with predominant stress urinary incontinence who underwent retropubic (TVT, n = 257) or TOT (n = 180) procedures were included. STIs for both groups were calculated by dividing cure by complication rate at, respectively, 2 and 12 months.nnnRESULTSnTwo months after surgery the STI was significantly higher after TOT whereas 12 months after surgery results of STIs were equal. The explanation is more durable cure rates and declining long-term side effects after TVT procedures.nnnCONCLUSIONnBoth surgical approaches seem to have their own benefits. Based on the STI, the balance between cure rate and complications is on the short term in favor of TOT but on the long term similar for TOT and retropubic TVT.

Rationale and design of the plate or pin (pop) study for dislocated midshaft clavicular fractures: study protocol for a randomised controlled trial

BackgroundTo describe the rationale and design of a future study comparing results of plate fixation and Elastic Stable Intramedullary Nailing (ESIN) with a Titanium Elastic Nail (TEN) for adults with a dislocated midshaft clavicular fracture.Methods/DesignProspective randomized multicenter clinical trial in two level 1 and one level 2 trauma centers. 120 patients between 18 and 65 years of age will be included. They are randomized to either plate fixation or ESIN with a TEN with a one year follow-up. Sixty patients will be treated with plate fixation and 60 patients will be treated with ESIN. Primary outcome parameter is the Disabilities of the Arm, Shoulder and Hand score after 6 months. Secondary outcome parameters are Constant Shoulder Score, complications, experienced pain, radiologic consolidation and cosmetics after both procedures.DiscussionProspective randomized studies comparing operative techniques for treatment of dislocated midshaft clavicular fracture are lacking. By studying shoulder function, complications, quality of life, radiographic union, cosmetics as well as experienced pain, a complete efficacy assessment of both procedures will be performed.Trial registrationThe POP study is registered in the Dutch Trial Register (NTR NTR2438).

When to perform urodynamics before mid-urethral sling surgery for female stress urinary incontinence?

Introduction and hypothesisDevelopment of a model that can predict in which group of women pre-operative urodynamics can be safely omitted.MethodsThree hundred and eighty-one uncomplicated women who underwent pre-operative urodynamics were evaluated. A multivariate logistic regression model was developed based on medical history and physical examination predicting a high probability group of women with detrusor overactivity or a low (<20xa0cm H2O) mean urethral closure pressure and, therefore, are likely to benefit from urodynamics.ResultsWomen are likely to benefit from pre-operative urodynamics if they (1) are 53xa0years of age or older or (2) have a history of prior incontinence surgery and are at least 29xa0years of age or (3) have nocturia complaints and are at least 36xa0years of age.ConclusionIf urogynaecologists omitted pre-operative urodynamics in women in the low probability group, in our population, pre-operative urodynamics would be reduced by 29%.

Perspectives by patients and physicians on outcomes of mid-urethral sling surgery

Introduction and hypothesisThe aim of this study is to determine patient expectations regarding wanted and unwanted sequels of mid-urethral sling (MUS) procedures and to identify mismatches during the physician–patient information exchange prior to MUS procedures.MethodsA patient preference study (40 patients) and a questionnaire study with 20 experts as control group were conducted. Seventeen different sequels, defined by an expert team, were evaluated.ResultsBoth patients and expert physicians ranked cure and improvement of stress urinary incontinence as the most important goals of treatment. De novo urge urinary incontinence, requiring post-operative intermittent self-catheterisation and dyspareunia were considered to be the most important complications by patients. Time to resume work after the operation and dyspareunia were among the highest rated sequels in the patient group compared to re-operation and intra-operative complications in the expert group.ConclusionsNo differences were found in the five most important outcome parameters. In pre-operative counselling and future clinical trials, time to resume work and dyspareunia should be given more consideration by clinicians.