Rates of subjective and objective cure, satisfaction, and pain 10-20 years after tension-free vaginal tape (TVT) surgery: A retrospective cohort study.

OBJECTIVE: To evaluate rates of subjective and objective cure, treatment satisfaction, pain, and the correlation between cure and body mass index (BMI), at 10 and 20 years after tension-free vaginal tape (TVT) surgery. DESIGN: Retrospective cohort study. SETTING: Multicentre study including 19 units in Norway. POPULATION: Women undergoing TVT surgery for stress urinary incontinence (SUI) during 2001-2006 (20-year cohort) and 2011-2012 (10-year cohort). METHODS: The Norwegian Female Incontinence Registry was used to identify women eligible for the study, who answered validated questionnaires about urinary incontinence, pain and satisfaction. MAIN OUTCOME MEASURES: Subjective cure of SUI (with stress index of <3, range 0-12), objective cure (<3 g on stress test) and persisting pain and satisfaction after TVT (scored on a five-point Likert scale). RESULTS: In total, 1210 of 1903 (64%) patients responded. The subjective cure rate was 68% after 10 years, versus 59% after 20 years, and did not significantly differ after adjusting for age, BMI, parity and preoperative stress index (adjusted OR 1.27, 95% CI 0.82-1.94). The objective cure rate was 100% versus 93% (P < 0.001), with 89% versus 76% reporting subjective satisfaction (P < 0.001), and with 4.7% versus 2.7% reporting persisting pain (P < 0.001), after 10 versus 20 years, respectively. Women in obesity classes I and II, compared with women of normal weight, had an increased risk of not being subjectively cured (crude OR 2.02, 95% CI 1.42-2.90; OR 2.95, 95% CI 1.60-5.46, respectively). CONCLUSIONS: Tension-free vaginal tape (TVT) provided high rates of subjective and objective cure at 10 and 20 years after surgery, with no significant difference between the two cohorts. Although 3%-5% of women experienced persisting pain, most women were satisfied with TVT surgery. Obesity was associated with a lower cure rate.

Long-term sexual function after mid-urethral slings for stress urinary incontinence in women.

INTRODUCTION: There has been increasing concern about potential negative impact of mid-urethral slings (MUS) on sexual life. Our aim was to study sexual activity 10-20 years after MUS surgery and changes in impact of incontinence on sexual life over time and to compare subjective cure, pain, satisfaction, and incontinence between sexually active and inactive women 10-20 years after MUS. MATERIAL AND METHODS: Historical cohort study using the Norwegian Female Incontinence Registry to identify women who underwent MUS between 2001-2006 and 2011-2012. They answered validated questionnaires about sexual activity, incontinence, pain, and satisfaction with MUS. We assessed changes in urinary incontinence during intercourse and compared symptoms and satisfaction between sexually active and inactive women. The study was registered in Clinical Trials (NCT04912830). RESULTS: In total, 1210/1903 (64%) responded. Of women responding to questions about sexual activity, 63% (735/1166) were sexually active. 31.3% experienced negative impact of incontinence on sexual life preoperatively, decreasing to 5.9% at 10-20 years follow-up. A higher proportion of sexually inactive vs sexually active women had urinary incontinence (63.5% vs. 47.5%, aOR 1.60 [1.18-2.17]). In a subanalysis, only urgency and mixed urinary incontinence remained significant. A higher proportion of sexually inactive were dissatisfied with MUS (30.1% vs. 12.9%, aOR 2.53 [1.82-3.51]). Persistent pain after MUS was similar for sexually inactive and active women (4.0% vs. 3.2%, aOR 1.10 [0.55-2.19]). Furthermore, 3.4% of sexually inactive had persistent pain after MUS and stated pain as a reason for not being sexually active, whereas 1.7% of sexually active women had persistent pain after MUS and pain during intercourse. CONCLUSIONS: Negative impact of incontinence on sexual life was less prevalent at 10-20 years follow-up after sling surgery compared to preoperative assessment. A higher proportion of sexually inactive had urgency and mixed urinary incontinence and were dissatisfied with MUS. Only 3%-4% of sexually active and inactive women had persistent pain after MUS and this was not associated with sexual activity. This indicates that incontinence has a greater negative impact on sexual activity than persisting pain after MUS at long-term follow-up.

Previous obstetrical history does not impact short-term mid-urethral sling outcomes.

INTRODUCTION AND HYPOTHESIS: Pregnancy and delivery are known risk factors for stress and mixed urinary incontinence. The most common surgical treatment is mid-urethral sling (MUS) surgery. This study evaluated the potential impact of the obstetrical history on the short-term subjective and objective failure rates after MUS surgery. METHODS: A registry-based surgical cohort study using data from the Medical Birth Registry of Norway (MBRN) and the national Norwegian Female Incontinence Registry (NFIR). Data from 14,787 women that underwent MUS surgery from 1998 to 2016 with complete registrations in the MBRN were included. Outcomes were 6-12-month postoperative subjective and objective failure rates. The potential impact of obstetrical and constitutional factors on both outcomes was tested in a multivariate logistic regression model. RESULTS: Several obstetrical variables seemed to impact both outcomes in the univariate analyses. However, in the multivariate analyses, none of the obstetrical variables significantly impacted subjective failure, and only being nulliparous before MUS surgery remained a risk factor for objective failure [aOR 1.60, (95% CI 1.07-2.40), p = 0.022]. High body mass index at time of surgery, non-retropubic slings, high preoperative urgency symptom load, and surgical complications were all strong risk factors for poor outcomes in the multivariate analyses. CONCLUSION: Although childbirth is considered a risk factor for developing stress urinary incontinence, childbirth does not appear to affect the result of MUS in parous women. Our results suggest that nulliparous women with SUI may have a different pathophysiology than SUI after childbirth.

Is antibiotic prophylaxis necessary in mid-urethral sling surgery?

INTRODUCTION AND HYPOTHESIS: Antibiotic prophylaxis is commonly used when implanting a mid-urethral sling (MUS) for female stress urinary incontinence. Use of antibiotics may lead to adverse events and the development of antibiotic resistance. This study compared a variety of outcomes after MUS surgery with and without antibiotic prophylaxis using data from the national Norwegian Female Incontinence Registry. METHODS: Preoperative and 6-12 months postoperative subjective and objective data from 28,687 patients who received MUS surgery from 1998 through 2017 were extracted from the registry. Categorical outcomes were compared between women with or without antibiotic prophylaxis using chi-square test for independence. Primary outcome was incidence of postoperative surgical site infection (SSI). Secondary outcomes were incidence of tape exposure, de novo or persistent urgency urinary incontinence, postoperative pain > 3 months, subjective and objective cure rates, and patient satisfaction. RESULTS: Antibiotic prophylaxis was used in 9131 and not used in 19,556 patients. SSIs and prolonged postoperative pain occurred significantly more often without antibiotic prophylaxis. Subjective and objective cure rates were significantly higher and tape exposures significantly lower in women not receiving prophylactic antibiotics. There were no significant differences in other outcomes. CONCLUSIONS: Antibiotic prophylaxis resulted in fewer women developing postoperative infections or prolonged postoperative pain after MUS surgery, but did not offer protection against tape exposure. The differences in cure rates were small and probably without clinical relevance. If a small increase in surgical site infections is accepted, the routine use of antibiotic prophylaxis can probably be omitted.

Comparing risk of repeat surgery for stress urinary incontinence after mid-urethral slings and polyacrylamide hydrogel.

INTRODUCTION: Over the last two decades synthetic mid-urethral slings (MUS) have become established as the main surgical method for correcting stress urinary incontinence (SUI). However, transurethral injections with polyacrylamide hydrogel are gaining popularity. We used surgical codes from a national registry to explore potential differences in risk of later surgery for SUI comparing retropubic slings, obturator slings, and polyacrylamide hydrogel injections. MATERIAL AND METHODS: This cohort study used surgical codes from The Norwegian Patient Registry. All women recorded as having had surgery for SUI coded as retropubic sling, obturator sling, or polyacrylamide hydrogel injection from 2008 until end-of-study censoring in 2017, were included. Main outcome was time to any recorded new SUI procedure later in the study period. Unadjusted comparison between groups was done using Kaplan-Meier. A Cox regression analysis was then performed to adjust for hospital unit size and patient age at surgery. RESULTS: The unadjusted analyses showed significant differences between the chosen index method and the risk of later SUI surgery favoring retropubic slings (p < 0.01). The proportions of patients without any recorded new SUI procedure at 1 and 5 years were 99.3% and 97.7% for retropubic MUS, 98.7% and 96.1% for obturator MUS, and 82.7% and 72.4% for polyacrylamide hydrogel injections. The majority of women having a repeat procedure for SUI after a polyacrylamide hydrogel injection underwent repeat treatment within 1 year (63%). After adjusting for age at time of surgery and hospital size, obturator slings (hazard ratio 1.8, 95% CI 1.4-2.4) and polyacrylamide hydrogel (hazard ratio 23.1, 95% CI 17.6-30.3) remained associated with a higher risk of later incontinence surgery. CONCLUSIONS: Both retropubic and obturator slings have low long-term risks of repeat incontinence surgery compared with polyacrylamide hydrogel injections. Retropubic slings were found to have superior longevity of the surgical result.

Comparison of retropubic midurethral slings in the treatment of female stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Over 50 different types of midurethral slings have been marketed. They have generally been considered comparable in performance. Many studies have compared retropubic with obturator slings, but few have compared different makes of retropubic slings with each other. We have compared the performance of retropubic slings using data from the Norwegian Female Incontinence Registry. METHODS: From June 2015 through 2017, 2843 women underwent a retropubic sling procedure, with 6-12-month follow-up data available for 2612 (92%). Results for six different types of slings used in this time period are presented: TVT Exact, TVT Classic, Advantage, Advantage Fit, TVT A.M.I. and RetroArc. The TVT Exact was the most prevalent sling, and the outcomes were compared with this sling as reference using chi-square and Dunnet's tests with significance at 0.05. RESULTS: There were only small differences among the four slings, TVT Exact, TVT Classic, Advantage and Advantage Fit, with subjective cure rates from 77.7 to 81.9% and objective cure rates from 90.8 to 96.6%. The TVT A.M.I. sling had a high cure rate but significantly fewer satisfied patients and less improvement in urgency bother. The Retro Arc's results were clearly inferior. There was little difference in terms of obstruction or de novo urgency incontinence among the six slings. Most complication rates were not statistically different. CONCLUSIONS: At 6-12-month follow-up there was no significant difference in clinical results between the TVT Exact, TVT Classic, Advantage and Advantage Fit slings, while RetroArc and to some extent TVT A.M.I. slings underperformed.

Childbirth after mid-urethral sling surgery: effects on long-term success and complications.

INTRODUCTION AND HYPOTHESIS: To evaluate long-term outcomes in women with one or more childbirths after mid-urethral sling (MUS) surgery and potential differences in outcomes based on mode of delivery. METHODS: A population-based cohort study using data from two national registries. Women registered with childbirth after MUS (case group) or without childbirth after MUS (control group), with equal follow-up time, underwent a structured telephone interview using a validated short-form urinary disease-specific questionnaire. Primary outcomes were current stress urinary incontinence (SUI) rate and change in cure rate. Secondary outcomes were effect of delivery mode, rates of repeat operations for SUI, complications, treatment satisfaction and urgency urinary incontinence rate. Childbirth as an independent risk factor for SUI recurrence was also evaluated. RESULTS: Seventy-two women with and 156 women without childbirth after MUS were included. Median follow-up time was 10 years for both groups. Subjective SUI cure rates were 82% (cases) and 75% (controls), respectively (p = 0.31). A significantly lower SUI cure rate was seen in the women with more than one childbirth after MUS (50% vs. 88% p = 0.006). No differences in primary or secondary outcomes were found between groups at follow-up, nor did mode of delivery affect outcomes. Childbirth after MUS was not an independent risk factor for subjective SUI recurrence (OR 0.8 CI 0.3-1.7). CONCLUSIONS: No differences in outcomes were seen between groups at follow-up independently of delivery mode. However, having more than one delivery after MUS seems to impact the continence status.

The completeness and accuracy of the Norwegian Female Incontinence Registry.

INTRODUCTION: Medical quality registries have gained popularity as tools for monitoring the quality of medical treatments and they serve as data sources for research. The Norwegian Female Incontinence Registry (NFIR) was established in 1998 to monitor and improve the quality of surgery for women with stress and mixed urinary incontinence in Norway and to collect data for research. This study aimed to assess the completeness and accuracy of the Norwegian Female Incontinence Registry, and potential differences in data accuracy over time and according to surgical volume of the reporting hospitals. MATERIAL AND METHODS: A random selection of 300 women from a total of 20 610 operated for urinary incontinence between 1998 and 2016 reported to the Norwegian Female Incontinence Registry from 28 public hospitals were selected for validation. The database completeness was estimated for 2008-2017 by comparing surgical procedures registered both in the Norwegian Female Incontinence Registry and the Norwegian National Patient Registry. Historical data recorded in the Registry for 10 selected key variables were extracted and compared with the patients' individual medical records at the reporting hospitals as reference. The reviewers were blinded to the previously stored information. The intraclass correlation coefficient for continuous variables and Cohen's kappa for categorical variables were calculated. RESULTS: Primary source data on 285 of the 300 women selected from Norwegian Female Incontinence Registry were successfully retrieved. The completeness of the registry has increased from 61% in 2008 to 99% in 2017. The national coverage has increased from 12 reporting departments in 1998 to all 38 public departments performing female incontinence surgery in 2017. Excellent accuracy was found for both continuous variables (intraclass correlation coefficient >0.94) and categorical variables (Cohen's kappa >0.86). No differences in data accuracy were found comparing high-volume hospitals with low-volume hospitals, or when comparing data accuracy over time. CONCLUSIONS: The Norwegian Female Incontinence Registry is a reliable tool for quality assessment of incontinence surgery and research. The registry completeness has improved over time and now contains data on nearly all women undergoing incontinence surgery in Norway.

Surgeon's experience and clinical outcome after retropubic tension-free vaginal tape-A case series.

INTRODUCTION: The retropubic tension-free vaginal tape procedure has been the preferred method for primary surgical treatment of stress and stress-dominant mixed urinary incontinence in women for more than 20 years. In this study, we assessed associations between surgeon's experience with the primary tension-free vaginal tape procedure and both perioperative complications and recurrence rates. MATERIAL AND METHODS: Using a consecutive case-series design, we assessed 596 patients treated with primary retropubic tension-free vaginal tape surgery performed by 18 surgeons from 1998 through 2012, with follow up through 2015 (maximum follow-up time: 10 years per patient). Data on perioperative complications and recurrence of stress urinary incontinence from medical records was transferred to a case report form. Surgeon's experience with the tension-free vaginal tape procedure was defined as number of such procedures performed as lead surgeon (1-19 ["beginners"], 20-49 and ≥50 procedures). All analyses were done with a 5% level of statistical significance. We applied the Chi-square test in the assessment of perioperative complications. The regression analyses of recurrence rate by number of tension-free vaginal tape procedures performed were restricted to the three surgeons who performed ≥50 procedures. RESULTS: We found a significantly higher rate of bladder perforations (P = .03) and a higher rate of urinary retentions among patients whose tension-free vaginal tape procedures were performed by "beginners" (P = .06). We observed a significant reduction in recurrence rates with increasing number of tension-free vaginal tape procedures for one surgeon (P = .03). CONCLUSIONS: Surgeon's experience with the tension-free vaginal tape procedure is associated with the risk of bladder perforation and urinary retention, and may be associated with the long-term effectiveness of the procedure.

Impact of levator muscle avulsions on Manchester procedure outcomes in pelvic organ prolapse surgery.

INTRODUCTION: Levator ani muscle avulsions potentially increase recurrence after anterior colporrhaphies. We aimed at evaluating the impact of avulsions on anatomical and patient-reported outcomes 1 year after the Manchester procedure for primary anterior compartment pelvic organ prolapse. MATERIAL AND METHODS: Prospective cohort study of 189 women undergoing the Manchester procedure between October 2014 and January 2017. Avulsions were diagnosed by transperineal ultrasound. Women with and without avulsions were compared for 1-year postoperative outcomes; Pelvic Organ Prolapse Quantification measurements, subjective satisfaction (1-worse to 4-cured), failure (new prolapse treatment), response to validated questionnaires on pelvic floor distress and sexual function, and a composite outcome (subjectively cured and optimal anterior compartment outcome (stage 0-I)). Optimal mid-compartment outcome was defined as cervix ≥5 cm above the hymen. Factors potentially associated with poor anatomical outcomes (anterior compartment stage ≥II) or pelvic floor distress were analyzed using regression analyses. RESULTS: Fewer women with avulsions (present in 50.8%) obtained optimal mid-compartment outcomes (88.2% vs 77.1%; P = 0.05). The groups were otherwise similar in terms of mid-compartment reduction, anterior compartment results, failure rate, subjective satisfaction, pelvic floor/sexual symptoms, and combined optimal subjective and anatomical outcome. Only preoperative anterior compartment stage ≥III was associated with poor anatomical outcome (P < 0.01). A high preoperative symptom score was associated with a high postoperative symptom score (P < 0.001). CONCLUSIONS: Although fewer women with avulsions obtained optimal mid-compartment results, avulsions had no impact on other anatomical or symptomatic outcomes 1 year after the Manchester procedure for primary anterior compartment prolapse.

The retropubic tension-free vaginal tape procedure-Efficacy, risk factors for recurrence and long-term safety.

INTRODUCTION: The retropubic tension-free vaginal tape has been the preferred method for primary surgical treatment of stress urinary incontinence and stress-dominated mixed urinary incontinence in women for more than 20 years. This study presents long-term safety and efficacy data and assesses risk factors for long-term recurrence. MATERIAL AND METHODS: In a case-series design we assessed a historical cohort of primary surgeries performed with the tension-free vaginal tape procedure in 596 women from 1998 to 2012 with follow up through 2015. Information from the medical records was transferred to a case report form comprising data on early and late complications and recurrence of urinary incontinence defined as bothersome stress urinary incontinence symptoms. All analyses were performed with SPSS using Pearson chi-square, survival and Cox regression analyses. RESULTS: After a 10-year follow up, mixed urinary incontinent women (hazard ratio 2.1, 95% confidence interval [CI] 1.4-3.0) had a significantly increased risk of recurrence of stress urinary incontinence symptoms compared with women with pure stress urinary incontinence as the indication for surgery. Overall cumulative cure rates after 1, 5 and 10 years were 92% (95% CI; 90%-94%), 79% (95% CI; 75%-83%) and 69% (95% CI; 63%-75%), respectively. Recurrent surgery (0.3%) and serious tape complications needing major surgical treatment (0.3%) were rare. Six patients (1.0%) had the tape cut due to urinary retention, and nine patients (1.5%) reported urinary retention more than 3 months after surgery. CONCLUSIONS: The tension-free vaginal tape procedure has a high long-term durability. Mixed urinary incontinence as an indication for surgery predicted long-term recurrence. Long-term complications were rare.

Fertility Outcome after Cornual Resection for Interstitial Pregnancies.

STUDY OBJECTIVE: To evaluate future pregnancy rates beyond gestational week 24 after cornual resections for interstitial pregnancies, subsequent modes of delivery, and the rate of later uterine ruptures. DESIGN: A single-center historic cohort with follow-up registry data (Canadian Task Force classification II-2). SETTING: Department of Gynecology, Oslo University Hospital, Oslo, Norway. PATIENTS: Forty consecutive women with interstitial ectopic pregnancies were treated in the study period from 2005 to 2016, 33 of whom were treated with laparoscopic cornual resection (3 converted to laparotomy). Twenty-six of the 33 women were presumed still fertile after treatment (cases) and thereby age and parity matched with a reference group of 52 women with an equal follow-up time having undergone salpingectomy for tubal (noninterstitial) ectopic pregnancies (controls) (ratio 1:2). Subsequent fertility data for both groups were retrieved from medical records and the national Medical Birth Registry of Norway. INTERVENTIONS: None, data extracted from the patients' medical records and the Medical Birth Registry of Norway. MEASUREMENTS AND MAIN RESULTS: The incidence of interstitial pregnancies among the ectopic pregnancies was 3%. The median time to follow-up for cases and controls was 76 and 71 months, respectively. Subsequent pregnancy rates beyond gestational week 24 were equal in both groups (46% [cases] and 54% [controls]). Cesarean delivery in subsequent pregnancies was more common among women having undergone cornual resections (60% vs 18%, p = .006). Only 2 subsequent uterine ruptures were encountered. CONCLUSION: Cornual resection as treatment for interstitial pregnancies seems to have no added detrimental effect on subsequent pregnancy rates compared with salpingectomy for noninterstitial tubal ectopic pregnancies. However, they more often lead to elective cesarean deliveries in subsequent pregnancies.

Mid-urethral slings in young, middle-aged, and older women.

AIMS: To compare subjective and objective outcomes of mid-urethral sling (MUS) surgery in women in different age decades and the utilization rates for MUS in Norwegian women. METHODS: Data from the national Norwegian Female Incontinence Registry on 21 832 women with stress or mixed urinary incontinence who underwent MUS surgery from 1998 to 2016 were used. Primary outcomes were treatment satisfaction and absence of objective stress leakage at 6-12 months follow-up and "MUS utilization rate." Secondary outcomes were increase in urgency incontinence symptoms and surgical complications. RESULTS: Women in the sixth decade and older had more objective postoperative stress urinary leakage, and women in the seventh decade and older were less satisfied. Urgency incontinence symptoms (persistent and de novo) after MUS increased with age. Intermittent catheterization occurred significantly more often in the seventh decade and bladder perforation in the seventh and eighth decades. Women younger than the fifth decade had fewer complications, except the need for tape transection in the fourth decade. The "MUS utilization rate" increased in all age groups during the study period, but declined slightly in the oldest age group after 2010. CONCLUSION: All age groups had a high percentage of "very satisfied" and no objective stress leakage at 6-12 months follow-up, but declining slightly with age after the sixth decade. Urgency incontinence symptom bother increased with age, but the overall complication rates were low. Our study strengthens the argument that management of stress urinary incontinence with MUS seems suitable regardless of age.

The Manchester procedure: anatomical, subjective and sexual outcomes.

INTRODUCTION AND HYPOTHESIS: Classical native-tissue techniques for pelvic organ prolapse (POP) repairs, such as the Manchester procedure (MP), have been revitalized because of vaginal mesh complications. However, there are conflicting opinions regarding sufficient apical (mid-compartment) support by the MP and concerns about the risk of dyspareunia. The aims of this study were therefore to investigate anatomical and patient-reported outcomes 1 year after MP. METHODS: Prospective cohort study of 153 females undergoing an MP for anterior compartment POP between October 2014 and June 2016. Pre- and 1-year postoperative evaluations included POP-Q measurements and the questionnaires Pelvic Floor Distress Inventory Short Form 20 (PFDI-20) and POP/Urinary Incontinence Sexual Questionnaire (PISQ-12). RESULTS: At 1 year, 97% (148/153) attended the follow-up. Significant anatomical improvements (p < 0.01) were obtained in all compartments. Mean Ba was -1.1 (± 1.4), mean C -5.9 (± 1.7) and mean D -7.0 (± 1.2) at follow-up. Point C ≤ -5 was present in 81.1%. POP-Q stage 0-1 was obtained in 99.3% in the mid-compartment (C < -1), but only in 48.6% in the anterior compartment (Ba < -1). A significant reduction in symptom scores was obtained for PFDI-20 (p < 0.01) and PISQ-12 (p = 0.01). No significant changes were seen in dyspareunia rates (q.5, PISQ-12), but 5.6% reported de novo dyspareunia. Concerning POP symptoms, 96.0% reported being cured or significantly improved. CONCLUSIONS: The Manchester procedure provides adequate apical support, albeit inferior anatomical anterior compartment results, and 96.0% reported being subjectively cured or substantially better at 1-year follow-up, with no significant change in dyspareunia.

Levator ani defects and the severity of symptoms in women with anterior compartment pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The aims of this study were to evaluate the prevalence of levator ani muscle (LAM) avulsions in a selected cohort of patients with primary anterior compartment pelvic organ prolapse (POP) and to assess whether LAM avulsions, as an independent factor, affect the degree of POP symptoms and sexual dysfunction. Additionally, clinical and demographic variables of women with and those without avulsions were compared. METHODS: We carried out a cross-sectional analysis of a prospective cohort study including 197 women scheduled for anterior compartment POP surgery. LAM avulsions were diagnosed on transperineal 4D ultrasound. Preoperative symptom severity and sexual dysfunction were evaluated using validated questionnaires (Pelvic Floor Disability Index [PFDI-20] and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-Short Form 12 [PISQ-12]). Linear regression was performed with avulsion as the main independent variable against total PFDI-20 and domain scores, bulge symptoms, and PISQ-12 score. Clinical and demographic variables for women with and without avulsions were compared using independent samples t test, Mann-Whitney U test or Chi-squared test. RESULTS: The prevalence of LAM avulsions was 50.3%. Avulsions were not associated with symptom severity or sexual dysfunction. "Chronic disease causing pain, fatigue or increased intra-abdominal pressure" was the only independent factor associated with all domains of the PFDI-20. Women with avulsions were younger at presentation, older at their first delivery, had lower BMI, and more often had a history of forceps delivery (p < 0.01). CONCLUSIONS: LAM avulsions were highly prevalent in this preoperative POP cohort. Avulsions were not associated with the severity of POP symptoms or sexual dysfunction. Women with avulsions seem to require fewer additional cofactors for developing POP.

Sling mobilization in the management of urinary retention after mid-urethral sling surgery.

OBJECTIVE: To compare intermittent catheterization, sling mobilization, and sling transection for treatment of urinary retention after mid-urethral sling surgery. METHODS: Data registered in the Norwegian Female Incontinence Registry from 1998 to 2013 were analyzed in this cohort study to compare subjective and objective outcomes after intermittent catheterization, sling mobilization, and sling transection as management of postoperative urinary retention after mid urethral sling surgery. Subjective outcomes were degree of symptom bother and the percentage of women stating "very satisfied" at the postoperative follow-up. The objective outcome was leakage at a cough-jump pad stress test. RESULTS: Intervention due to urinary retention was performed in 585 of 18,772 women (3.1%). Women who had their sling mobilized or had intermittent catheterization, scored better on all postoperative outcomes than those who had their sling transected (P < 0.001). Sling transection was more often needed after intermittent catheterization than after mobilization (P = 0.023). No outcome differences were found between intermittent catheterization only and sling mobilization only. Intention to treat analysis showed that women who underwent sling mobilization as the primary procedure significantly more often had a negative stress test (P = 0.033) and were more often "very satisfied" with the treatment (P = 0.006) than those who were primarily catheterized. CONCLUSIONS: Sling mobilization is a more successful treatment than intermittent catheterization or transection for urinary retention after mid-urethral sling surgery. CLINICAL TRIAL REGISTRATION: Clinical trial registration was not applicable because this study is based on an analysis of anonymous data from The Norwegian Female Incontinence Registry. Neurourol. Urodynam. 36:1091-1096, 2017. © 2016 Wiley Periodicals, Inc.

Long-term clinical outcomes with the retropubic tension-free vaginal tape (TVT) procedure compared to Burch colposuspension for correcting stress urinary incontinence (SUI).

INTRODUCTION AND HYPOTHESIS: The retropubic tension-free vaginal tape (TVT) procedure replaced Burch colposuspension as the primary surgical method for stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) in women in our department in 1998. In this study we compared the short-term and long-term clinical outcomes of these surgical procedures. METHODS: Using a case series design, we compared the last 5 years of the Burch procedure (n = 127, 1994-1999) with the first 5 years of the retropubic TVT procedure (n = 180, 1998-2002). Information from the medical records was transferred to a case report form comprising data on perioperative and long-term complications as well as recurrence of UI, defined as bothersome UI or UI in need of repeat surgery. Other endpoints were rates of perioperative and late complications and the rates of prolapse surgery after primary surgery. The data were analyzed with the chi-squared and t tests and survival analysis using SPSS. RESULTS: The cumulative recurrence rate of SUI in women with preoperative SUI was significantly higher after the Burch procedure, but no difference was observed in women with MUI. There were no significant differences in rates of perioperative and late complications. At 12 years there was a significant increase in rates of repeat surgery for incontinence and prolapse in women after the Burch procedure. CONCLUSIONS: The long-term efficacy of TVT surgery was superior to that of Burch colposuspension in women with SUI. In addition, the rate of late prolapse surgery was significantly higher after the Burch procedure.

Risk factors for long-term failure of the retropubic tension-free vaginal tape procedure.

AIMS: To investigate potential risk factors for long-term (10-year) subjective and objective failure of the retropubic tension-free vaginal tape procedure (TVT). METHODS: Secondary risk analysis was performed using data from a recently published multi-center study that were merged with additional preoperative and operative data individually stored in the Norwegian Female Incontinence Registry (NFIR). Subjective data from 483 women and objective data from 327 women were obtained 10 years after retropubic TVT surgery. A validated questionnaire was used for subjective outcome data and a stress test for objective outcome data. Uni- and multivariate logistic regression analyses were performed using preoperative and operative variables extracted from the NFIR. The outcomes were 10-year subjective failure defined as women stating not cured, and objective failure was defined as ≥1 g urinary leakage during stress testing. RESULTS: Age ≥56 years at the time of TVT surgery was associated with both long-term subjective failure (adjusted OR: 2.15, CI: 1.40-3.30) and long-term objective failure (adjusted OR: 2.81, CI: 1.30-6.09). Mixed incontinence was associated with subjective, but not objective failure if the urgency incontinence component was severe (adjusted OR: 2.33, CI: 1.27-4.28). Surgical complications occurring at or immediately following surgery were associated with both outcomes in the univariate analyses, but were only an independent risk factor for subjective failure in the multivariate analysis (adjusted OR: 3.02, CI: 1.53-5.95). CONCLUSIONS: Age ≥56 years, a severe preoperative urgency incontinence component and surgical complications seem to represent independent risk factors for long-term (10-year) failure.

Long-term follow-up after native tissue repair for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: There are large variations in reported frequency of recurrence and subsequent treatment after pelvic organ prolapse (POP) surgery. We hypothesized that native tissue repair entails high subjective satisfaction and good objective results, with low POP reoperation rates and few complications. METHODS: The 1-year results of 699 women having had native tissue repair for POP at our urogynecological unit from 2002 to 2005 were evaluated using an internal quality control database. A short-form physician check list for patient subjective and objective outcomes has been routinely used for 1-year controls since 2002, and results are registered longitudinally in the database. Patients' medical records up to 2012 were reviewed for information on recurrent POP symptoms. A telephone interview was performed to assess POP recurrences potentially treated elsewhere. The cumulative incidence for reoperation was calculated comparing partial with complete (surgical treatment of all three compartments) native tissue repairs. RESULTS: Subjective satisfaction was stated by 94 % of patients at the 1-year control, and 84 % had stage 0-I in any compartment using the POP Quantification (POP-Q) system. The 5-year reoperation rate was significantly lower in the complete vs. the partial (2.6 % vs. 8.9 %) repair group. Cumulative incidence of reoperation showed a slight but constant increase over the years. CONCLUSIONS: POP surgery using native tissue repair entails low reoperation rates with excellent subjective and objective results and should be the first choice in treating primary POP, providing use of adequate surgical technique.