Hypothesis / aims of study
Though the efficiency of the midurethral sling is high, 5% to 35% of patients experience surgical failure. [1] Moreover, the repeat surgical interventions have significantly lower cure rate, than those in primary patients. [2] The improper tensioning may lead to ineffectiveness of the procedure; it can cause both persistent incontinence and voiding disorders. The survey results show 83,3% of surgeons consider the tape tension is important or very important factor of success, however among surgeons there is no common opinion on how to choose the proper tension. [3] As well, there is no clear guidance on choosing the best way to treat patients with recurrent SUI or those, who have risk factors for failure of the surgery. The purpose of the study was to evaluate the efficacy of transobturator adjustable midurethral sling procedure in complicated cases of SUI or mixed urinary incontinence.
Study design, materials and methods
This prospective study comprised 70 women with SUI or mixed urine incontinence, who had predictive factors of failure, such as fixed urethra (Q-tip<30°), intrinsic sphincter deficiency (ICD), history of previous incontinence surgery or pelvic organ prolapse repair or concomitant prolapse ≤2 stage (POP-Q). The mean age of the enrolled patients was 58,07±9,65 years. All patients underwent the transobturator adjustable midurethral tape procedure. We used a monofilament polypropylene sling with special threads, that allow to adjust its tension. (Fig.1) The pre- and postoperative evaluation included medical history, vaginal examination, cough stress test in supine and standing position, urodynamics, bladder ultrasound and post-void residual (PVR) urine measurement, questionnaires (UDI-6, UIQ-6, PFIQ-7, ICIQ-SF).
Results
Mean follow-up was 12,15 ± 1,47 months. Mean operating time was 16,76 ± 10,01 min. Data on patients who underwent the sling tension adjusting is presented in Tab.1. The increasing of the tape tension the next day after surgery was required in 33 patients (47,14%). This procedure was repeated in 9 (12,85%) of them as the stress test was positive at the following examination. The adjustment was ineffective in 2 (2,85%) women, who demonstrated continuous urinary incontinence. During follow-up the leakage was persistent, therefore after 6 month follow-up both patients underwent a retropubic midurethral sling procedure, which was effective. After surgery, 12 (17,14%) women complained on slow or intermittent stream, and spraying of the urine. All of those women had obstructive flow pattern, combined with >100 ml PVR in 6 (8,57%) cases. After adjustment all patients were continent, with PVR ≤ 60 ml. No cases of intraoperative bladder or urethral injury were detected. There was one case of significant blood loss (<300 ml), that was managed with the tight tamponade of the vagina for 12 h. In early postoperative period 2 (2,85%) women complained of groin pain. As the complete relief was not achieved by oral analgetics, the pain was resolved within 3 weeks by trigger point injections. No tape excision were required. The results of 12-month follow-up are presented at Tab.2. The objective cure rate was 94,28% (n=66). There was no significant decrease of Qmax (p=0,542). There were no cases of wound infections, vaginal mesh extrusion or urinary obstruction. The incidence of de novo urge incontinence was 2,85% (n=2), de novo urgency rate was 7,14% (n=5). The questionnaires scores showed 90,0% (n=63) patients to be very satisfied with great improvement of quality of life (p<0,001).