Impact of a mid-urethral synthetic mesh sling on long-term risk of systemic conditions in women with stress urinary incontinence: a national cohort study.

OBJECTIVE: To compare the incidence of systemic conditions between women who had surgical treatment for stress incontinence with mesh and without mesh. DESIGN: National cohort study. SETTING: English National Health Service. POPULATION: Women with no previous record of systemic disease who had first-time urinary incontinence surgery between 1 January 2006 and 31 December 2013, followed up to the earliest of 10 years or 31 March 2019. METHODS: Competing-risks regression was used to estimate hazard ratios (HR), adjusted for patient characteristics, with HR > 1 indicating increased incidence following mesh surgery. MAIN OUTCOME MEASURES: First postoperative admission with a record of autoimmune disease, fibromyalgia or myalgic encephalomyelitis up to 10 years following the first incontinence procedure. RESULTS: The cohort included 88 947 women who had mesh surgery and 3389 women who had non-mesh surgery. Both treatment groups were similar with respect to age, socio-economic deprivation, comorbidity and ethnicity. The 10-year cumulative incidence of autoimmune disease, fibromyalgia or myalgic encephalomyelitis was 8.1% (95% CI 7.9-8.3%) in the mesh group and 9.0% (95% CI 8.0-10.1%) in the non-mesh group (adjusted HR 0.89, 95% CI 0.79-1.01; P = 0.07). A sensitivity analysis including only autoimmune diseases as an outcome returned a similar result. CONCLUSIONS: These findings do not support claims that synthetic mesh slings cause systemic disease. TWEETABLE ABSTRACT: No evidence of increased risk of systemic conditions after stress incontinence treatment with a mesh sling.

Long-term efficacy and complications of a multicentre randomised controlled trial comparing retropubic and transobturator mid-urethral slings: a prospective observational study.

OBJECTIVE: There are concerns regarding the risks of mid-urethral slings (MUS) for stress urinary incontinence (SUI), particularly because of the lack of long-term data. We compare patient-reported outcomes of a multicentre randomised controlled trial of retropubic (TVT, GYNECARE™) versus transobturator (TOT, MONARC™) tape surgery at 12 years. DESIGN AND SETTING: A multicentre study was performed in 11 tertiary referral centres. POPULATION: A cohort of 180 participants from the original trial, the majority of whom had mixed urinary incontinence. METHODS: Postal questionnaire survey of patient-reported outcome measures using the International Consultation on Incontinence Questionnaire, Patient Global Impression of Improvement questionnaire (PGI-I) and a numeric rating scale pain questionnaire. MAIN OUTCOME MEASURES: Comparison of the efficacy and complications between the TVT and TOT procedures in the long term. RESULTS: A total of 110/180 responses were received: 55 for TVT and 55 for TOT. The mean follow-up was 12.8 ± 0.29 years (SD). TVT was significantly superior to TOT: 41.8% TVT with no SUI, versus 21.8% TOT (P = 0.04). Urgency urinary incontinence (UUI) was the most bothersome urinary symptom: 14.5% of respondents reported UUI after TVT and TOT. This was an improvement from the baseline levels: 61.8% TVT and 76.4% TOT. Seventeen patients (9 TVT and 8 TOT) out of 121 reported moderate or severe pain with severe pain in 3 with TVT and 2 with TOT. Overall, 80% TVT and 77% TOT participants reported their symptoms as improved on the PGI-I. CONCLUSIONS: TVT is superior to TOT for SUI cure. Efficacy is reduced by 12 years. There is low incidence of severe vaginal or groin pain. Careful patient counselling on long-term outcomes is required. The Retropubic tape appears to be an effective treatment for the majority of women with SUI. TWEETABLE ABSTRACT: Retropubic tape has superior efficacy to transobturator tape. Complications are comparable with low rates.

Cost-effectiveness of behavioral and pelvic floor muscle therapy combined with midurethral sling surgery vs surgery alone among women with mixed urinary incontinence: results of the Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence randomized trial.

BACKGROUND: Urinary incontinence is prevalent among women, and it has a substantial economic impact. Mixed urinary incontinence, with both stress and urgency urinary incontinence symptoms, has a greater adverse impact on quality of life and is more complex to treat than either stress or urgency urinary incontinence alone. Studies evaluating the cost-effectiveness of treating both the stress and urgency urinary incontinence components simultaneously are lacking. OBJECTIVE: Cost-effectiveness was assessed between perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery and midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. The impact of baseline severe urgency urinary incontinence symptoms on cost-effectiveness was assessed. STUDY DESIGN: This prospective economic evaluation was performed concurrently with the Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence randomized trial that was conducted from October 2013 to April 2016. Participants included 480 women with moderate-to-severe stress and urgency urinary incontinence symptoms and at least 1 stress urinary incontinence episode and 1 urgency urinary incontinence episode on a 3-day bladder diary. The primary within-trial analysis was from the healthcare sector and societal perspectives, with a 1-year time horizon. Costs were in 2019 US dollars. Effectiveness was measured in quality-adjusted life-years and reductions in urinary incontinence episodes per day. Incremental cost-effectiveness ratios of combined treatment vs midurethral sling surgery alone were calculated, and cost-effectiveness acceptability curves were generated. Analysis was performed for the overall study population and subgroup of women with Urogenital Distress Inventory irritative scores of ≥50th percentile. RESULTS: The costs for combined treatment were higher than the cost for midurethral sling surgery alone from both the healthcare sector perspective ($5100 [95% confidence interval, $5000-$5190] vs $4470 [95% confidence interval, $4330-$4620]; P<.01) and the societal perspective ($9260 [95% confidence interval, $8590-$9940] vs $8090 [95% confidence interval, $7630-$8560]; P<.01). There was no difference between combined treatment and midurethral sling surgery alone in quality-adjusted life-years (0.87 [95% confidence interval, 0.86-0.89] vs 0.87 [95% confidence interval, 0.86-0.89]; P=.90) or mean reduction in urinary incontinence episodes per day (-4.76 [95% confidence interval, -4.51 to 5.00] vs -4.50 [95% confidence interval, -4.25 to 4.75]; P=.13). When evaluating the overall study population, from both the healthcare sector and societal perspectives, midurethral sling surgery alone was superior to combined treatment. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone is ≤28% from the healthcare sector and ≤19% from the societal perspectives for a willingness-to-pay value of ≤$150,000 per quality-adjusted life-years. For women with baseline Urogenital Distress Inventory irritative scores of ≥50th percentile, combined treatment was cost-effective compared with midurethral sling surgery alone from both the healthcare sector and societal perspectives. The probability that combined treatment is cost-effective compared with midurethral sling surgery alone for this subgroup is ≥90% from both the healthcare sector and societal perspectives, at a willingness-to-pay value of ≥$150,000 per quality-adjusted life-years. CONCLUSION: Overall, perioperative behavioral and pelvic floor muscle therapies combined with midurethral sling surgery was not cost-effective compared with midurethral sling surgery alone for the treatment of women with mixed urinary incontinence. However, combined treatment was of good value compared with midurethral sling surgery alone for women with baseline severe urgency urinary incontinence symptoms.

[Trends in the use of midurethral slings after the new legislation: A nationwide survey]. / Évolution des pratiques après l'arrêté encadrant les bandelettes sous-urétrales : résultats d'une enquête nationale.

INTRODUCTION: The French Department of Health published on October 23, 2020 a decree governing acts associated with mid-urethral sling (MUS) operations. The aim of this study was to evaluate the changes in practice following this new legislation. METHODS: A cross-sectional study was carried out among French urologists and gynecologists using an online survey to collect changes in practices since the publication of the decree. RESULTS: From January to February 2021, 436 surgeons participated in the survey. Among these surgeons, 87% were aware of the new legislation and 56% of them considered the decree as useless. The order resulted in an increase in working time in 81% of cases. Among these surgeons, 66% of the surgeons worked in tertiary referral centers for the management of incontinence, of which 55% had a multidisciplinary meeting in urogynecology. Among the surgeons, 31% considered this meeting to be useful but 80% considered that it did not lead to any change in surgical indications, even though 33% of complications of BSU were discussed there. In conclusion, 61% of surgeons felt more reluctant to schedule a BSU placement with this new legislation. CONCLUSION: The majority of questioned surgeons considered the decree as useless. It generated few changes in practices which already respected the law on information, consultation, consent, experience and training. Most urologists and gynecologists are more reluctant to offer MUS after this new legislation. LEVEL OF EVIDENCE: 4.

Association Between Hemoglobin A1c and Midurethral Sling Complications in Diabetic Women: A Cohort Study.

OBJECTIVE: We aimed to evaluate the association between hemoglobin A1c (HbA1c) levels and midurethral sling (MUS) complications. METHODS: This was a multihospital, retrospective cohort study from 2010 to 2020. We included all women with diabetes mellitus who underwent a synthetic mesh MUS procedure and had a preoperative HbA1c within 3 months of surgery. The primary outcome was a composite of complications, including MUS mesh exposure, surgical site granulation tissue or infection, urinary tract infection, surgical site pain beyond 6 weeks postoperatively, and MUS failure. A sensitivity analysis analyzing MUS failure alone was performed. RESULTS: During the study period, 109 women met the inclusion criteria. Most were White (52.2%) and had a median body mass index of 31.2 kg/m2, and 84.9% were postmenopausal. Median HbA1c was 7.2% (interquartile range, 6.3%-7.7%). Urinary tract infection was the most common complication in 12 (11.0%) women. Mesh exposure was diagnosed in 7 (6.4%) women. Seventeen (15.6%) had MUS failure. On univariate regression analysis, a higher HbA1c was associated with increased odds of composite complications (odds ratio, 1.67; 95% confidence interval, 1.20-2.32; P = 0.002) and MUS failure (odds ratio, 1.81, 95% confidence interval, 1.26-2.60; P = 0.001). On multivariate analysis, higher HbA1c levels were associated with a composite of complications and failure (P < 0.05). Based on the receiver operating characteristic curve, HbA1c greater than 8% demonstrated a specificity of 85.7% and a sensitivity of 50% for MUS failure. CONCLUSIONS: In diabetic patients, a higher HbA1c was associated with a higher risk of MUS complications and failure. Obtaining an HbA1c within 3 months of surgery may help with risk stratification.

Timing and Success of Postoperative Voiding Trial After Colpocleisis With and Without Concomitant Midurethral Sling.

OBJECTIVE: The aim of this study was to compare failure rates of first voiding trial (VT) within 7 days and on postoperative day (POD) 1 after colpocleisis with versus without concomitant midurethral sling (MUS). Predictors of POD 1 VT failure were also examined. METHODS: This was a retrospective cohort study of women undergoing colpocleisis from January 2012 to October 2019 comparing VT outcomes with versus without MUS. Primary outcome was first VT failure within 7 days; outcomes of VTs performed on POD 1 were also assessed. Association between MUS and VT failure and predictors of POD 1 VT failure were assessed via logistic regression. RESULTS: Of 119 women, 45.4% had concomitant MUS. First VT was performed on mean POD 3.1 ± 2.2 in the MUS group versus POD 1.8 ± 1.8 in the no MUS group (P < 0.01). The MUS group was less likely to undergo POD 1 VT (50% vs 83%, P < 0.01). Failure of the first VT did not differ (22.2% with MUS vs 32.8% without MUS, P = 0.20); no association between VT failure and MUS was noted (adjusted odds ratio [aOR], 0.6; 95% confidence interval [CI], 0.18-2.1). There were 68.1% (81/119) of participants who underwent POD 1 VT, MUS was performed in 33.3% (27/81). The POD 1 failure did not differ between those with 33.3% versus 40.7% without MUS (P = 0.52). Midurethral sling was not associated with POD 1 VT failure (aOR, 0.93; 95% CI, 0.27-3.23). In women undergoing POD 1 VT, preoperative postvoid residual was associated with VT failure (aOR, 1.39; 95% CI, 1.01-1.92). CONCLUSIONS: In women undergoing colpocleisis, MUS was not associated with VT failure within 7 days or on POD 1. Increased preoperative postvoid residual was associated with POD 1 VT failure.

Rates of Sling Procedures and Revisions-A National Surgical Quality Improvement Program Database Study.

OBJECTIVE: The aim of this study was to describe trends in sling procedures and revisions, including fascial slings and midurethral slings (MUS) using a large, national database with respect to the 2011 U.S. Food and Drug Administration (FDA) mesh-related safety communication. METHODS: This was a cross-sectional cohort study using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010 to 2018, evaluating the prevalence of sling revision and fascial slings and their trends over time. Patients who underwent MUS, fascial slings, and sling revisions were identified by Current Procedural Terminology codes. Sling revisions and fascial slings were evaluated as a proportion of the total number of MUS performed per year. Three distinct periods were evaluated in relation to the 2011 FDA communication: 2010 to 2012, 2012 to 2015, and 2015 to 2018. Observed trends were assessed with Pearson correlation coefficients with a P value less than 0.05 considered significant. RESULTS: During the study period, 32,657 slings were captured: 32,389 MUS and 268 fascial slings. The rate of sling revisions was low (0.4% in 2010 to 1.2% in 2015). Between 2012 and 2015, the rate of sling revision increased significantly (R = 1, P = 0.002); following 2015, the rate of sling revisions decreased significantly over time (R = -0.96, P = 0.04). The rate of fascial slings between 2012 and 2015 increased significantly (R = 0.95, P = 0.047); however, the rate plateaued starting in 2015 (R = -0.49, -P = 0.51). CONCLUSIONS: Our data suggest that MUS remain the preferred procedure for treatment of stress urinary incontinence despite the recent FDA communications with MUS representing 99% of sling procedures during the study period.

Risk Factors for Intraoperative Bladder Perforation at the Time of Midurethral Sling Placement.

OBJECTIVE: To evaluate patient-specific and perioperative factors that may be predictive of bladder perforation during midurethral sling placement. METHODS: A retrospective chart review of women who underwent a midurethral sling procedure at our institution between 2013 and 2017 was completed. All cases with bladder perforation were included. Patient demographics and perioperative factors were explored for associations with perforation. Bivariate analysis was used to compare baseline characteristics between those with and without perforation. Logistic regression modeling was used to identify predictors of perforation and associations between bladder perforation and postoperative sequelae. RESULTS: Four hundred and ten women had a urethral sling procedure at our institution between 2013 and 2017. Of these, 35 (9%) had evidence of bladder perforation on cystoscopy. This rate was higher for retropubic slings (15%) compared to transobturator slings (2%). Those with a perforation were younger (54 vs 61 years, P= .004) and had a lower average BMI (24.1 kg/m2 vs 26.3 kg/m2, P = .022). Other risk factors included lack of pre-existing apical prolapse (11% vs 4%, P = .012) and concomitant urethrolysis (27% vs 8%, P = .024). In multivariable analysis, age, BMI, and sling type were significantly associated with perforation. In univariate analysis, perforation was associated with postoperative lower urinary tract symptoms (OR 2.3, P = .21) and urinary tract infection within 30 days of surgery (OR 2.2, P = .047). CONCLUSIONS: Intraoperative bladder perforation was associated with younger patient age and lower BMI. Additionally, bladder perforation is a risk factor for postoperative urinary tract infection and lower urinary tract symptoms.

Trends of Mesh Utilization for Stress Urinary Incontinence Before and After the 2011 Food and Drug Administration Notification Between FPMRS-Certified and Non-FPMRS-Certified Physicians: A Statewide All-Payer Database Analysis.

OBJECTIVES: To investigate the utilization of mesh slings for stress urinary incontinence (SUI) across time - before and after the 2011 US Food and Drug Administration (FDA) public health notification regarding an increase in adverse events related to transvaginal mesh (TVM) for pelvic organ prolapse (POP) repair - and among FPMRS-certified urologists and gynecologists and non-FPMRS counterparts using a statewide database. METHODS: The New York Statewide Planning and Research Cooperative System all-payer database was utilized to extract outpatient Current Procedural Terminology procedure codes for SUI mesh sling utilization and revision or removal performed between 2007 and 2015. RESULTS: After the 2011 FDA warning on POP with TVM, sling placement decreased by 43% from 5214 cases in 2011 to 2958 in 2015. However, over the study period, the rate of sling revision remained stable relative to total sling placement. The rise and fall in mesh sling usage for SUI was primarily driven by non-FPMRS providers. FPMRS providers performed a higher proportion of sling procedures. The number of FPMRS physicians also increased from 2011 to 2015, and each individual physician had a higher median case volume for sling placements and revisions. CONCLUSION: In New York state, utilization of mesh slings for SUI has significantly decreased since the 2011 FDA public health notification, without any specific warning for the utilization of mesh in this setting. This trend was mainly driven by a decrease in mesh usage among non-FPMRS physicians, although the specific causality is likely complex.

Cadaveric Laboratory Simulation Training of Male Stress Urinary Incontinence Treatment Improves Trainee Knowledge and Confidence.

OBJECTIVE: To assess whether a focused, simulation training course can improve trainee surgical knowledge and confidence in the treatment of male stress urinary incontinence. MATERIALS AND METHODS: Urology residents participated in a prosthetic education course as part of the 2018 SUPS and SMSNA annual meeting. The course included didactic lectures and a hands-on cadaveric laboratory. Participants completed questionnaires before and after the lab (2 weeks and 6 months) to assess procedural knowledge and confidence. Analysis of lab responses was performed using the Wilcoxon signed rank test for matched pairs. RESULTS: Thirty-two residents (median age 29, range 27-34) participated in the course. The majority were postgraduate year 4 (63%) or postgraduate year 5 (20%). Most participants reported minimal AUS or sling experience with 50% and 94% reporting less than 5 cases, respectively. Overall score from the knowledge assessment improved significantly between the pre-lab versus 2-week post-lab (P = .02) and pre-lab versus 6-month post-lab (P = .01). Similarly, procedural confidence improved between pre-lab vs 2-week post-lab (P < .001) and pre-lab versus 6-month post-lab (P < .001). Knowledge and confidence assessments were not different between year of residency training or pre-lab experience. CONCLUSIONS: Simulation training improves knowledge and confidence in prosthetic surgery for male stress incontinence. In the current climate of reduced exposure and limited availability of prosthetic educators, simulation courses can provide much needed educational value.

Female neurogenic stress urinary incontinence.

PURPOSE OF REVIEW: The aim of this article is to look into recent updates on the management of neurogenic stress urinary incontinence (NSUI) in adult females. RECENT FINDINGS: Recently, a small number of studies have investigated different surgical modalities in treatment of NSUI in adult females including artificial urinary sphincter (AUS), suburethral tapes (SUT) and adjustable slings and urethral bulking agents. Up to 70% of neurogenic patients who received AUS implants are continent and have not required surgical revision over a 20-year follow-up period. However, the risk for explantation of AUS may be twice as high in neurogenic patients compared with nonneurogenic patients. SUT have success and improvement in quality of life rates of up to 52 and 68%, respectively. However, complications may be as high as 24%. Early data on adjustable slings may suggest up to 80% continence with low complication rates. SUMMARY: AUS can provide satisfactory continence levels with acceptable rates of revision and explantation. SUT are effective but more than half of patients may require additional procedures. Adjustable slings could be a promising option. Further high-quality studies with careful attention to methodology and standardization of both definitions used and outcome reporting are required to help us reach safe conclusions.

Adjustable bulbourethral male sling: Experience after 30 cases of moderate to severe male stress urinary incontinence.

OBJECTIVE: To report our experience using the Argus perineal sling from July 2015 to April 2018 for male stress urinary incontinence (SUI) after prostatic surgery. To evaluate the safety, efficacy and healthrelated quality of life in patients undergoing this procedure. PATIENTS AND METHODS: The positioning of an adjustable bulbourethral male sling provides a perineal incision, exposure of the bulbospongiosus muscle and the application of the sling bearing on it with transobturator passage of the two extremities with out-in technique. To modulate the bearing tension on the urethra, with a rigid cystoscope the Retrogade Leak Point Pressure is measured, increasing it by 10-15 cm of H20 from baseline. We retrospectively evaluated the results of this implant performed by the same operator on 30 patients who presented post-operative SUI from medium to severe (> = 2 pads/day, pad test at one hour > = 11 g). Mean operative time and possible intra and postoperative complications were evaluated. Postoperatively each patient was reassessed according to the following parameters: number of pads consumed/ die, pad tesy at one hour, ICQS-F, any related side effects. RESULTS: After the intervention, 21 of 30 patients (70% of the total) were totally continent (< 1 pad / day, pad test at 1 h < 1-2 g, ICQS-F < 11), out of them 4 required a single adjustment at 3 months in order to achieve this result. 9 of 30 patients (30 %) achieved a clinically significant improvement without obtaining total continence (mean reduction of the n° pads/day: -2.5 ± 1 DS; average reduction of the pad test at 1 h: -20 g ± 4 DS; ICQS-F average reduction: -6 points ± 2 DS), out of them 5 required a 3 month adjustment to obtain these improvements resulting, 4 needed 2 adjustments resulting because the first adjustment was not satisfactory and one who ameliorated from severe to moderate incontinence decided to live in this clinical condition. CONCLUSIONS: The results of our study show that the positioning of this sling represents a valid treatment for the moderate and severe post-surgical male SUI. The possibility of adjusting the tension of the sleeve in a "second look" makes the intervention adaptable according to the results obtained. Only multicentric clinical trials on larger series would clarify and eventually confirm the clinical benefits of this sling in post-surgical male SUI.

Complications after pelvic floor repair surgery (with and without mesh): short-term incidence after 1873 inclusions in the French VIGI-MESH registry.

OBJECTIVE: To assess the short-term incidence of serious complications of surgery for urinary incontinence or pelvic organ prolapse. DESIGN: Prospective longitudinal cohort study using a surgical registry. SETTING: Thirteen public hospitals in France. POPULATION: A cohort of 1873 women undergoing surgery between February 2017 and August 2018. METHODS: Preliminary analysis of serious complications after a mean follow-up of 7 months (0-18 months), according to type of surgery. Surgeons reported procedures and complications, which were verified by the hospitals' information systems. MAIN OUTCOME MEASURES: Serious complication requiring discontinuation of the procedure or subsequent surgical intervention, life-threatening complication requiring resuscitation, or death. RESULTS: Fifty-two women (2.8%, 95% CI 2.1-3.6%) experienced a serious complication either during surgery, requiring the discontinuation of the procedure, or during the first months of follow-up, necessitating a subsequent reoperation. One woman also required resuscitation; no women died. Of 811 midurethral slings (MUSs), 11 were removed in part or totally (1.4%, 0.7-2.3%), as were two of 391 transvaginal meshes (0.5%, 0.1-1.6%), and four of 611 laparoscopically placed mesh implants (0.7%, 0.2-1.5%). The incidence of serious complications 6 months after the surgical procedure was estimated to be around 3.5% (2.0-5.0%) after MUS alone, 7.0% (2.8-11.3%) after MUS with prolapse surgery, 1.7% (0.0-3.8%) after vaginal native tissue repair, 2.8% (0.9-4.6%) after transvaginal mesh, and 1.0% (0.1-1.9%) after laparoscopy with mesh. CONCLUSIONS: Early serious complications are relatively rare. Monitoring must be continued and expanded to assess the long-term risk associated with mesh use and to identify its risk factors. TWEETABLE ABSTRACT: Short-term serious complications are rare after surgery for urinary incontinence or pelvic organ prolapse, even with mesh.

Overactive Bladder Symptoms After Pelvic Organ Prolapse Repair.

OBJECTIVES: This study aimed to identify the characteristics associated with overactive bladder (OAB) symptoms perioperatively in patients undergoing pelvic organ prolapse (POP) surgery with and without slings and to determine the rate of OAB symptom resolution postoperatively. METHODS: This retrospective, single-institution study involved women undergoing prolapse surgery with and without concomitant midurethral sling from 2011 to 2016. A validated questionnaire was used to determine OAB symptoms preoperatively and postoperatively. The primary outcome was rate of resolution in OAB symptoms after POP surgery with and without midurethral sling. Baseline characteristics and surgery type were presented, and univariate and multivariate logistic regression models were applied to evaluate characteristics associated with OAB symptoms at the first postoperative visit. RESULTS: The analysis included 203 patients. Among those with baseline OAB symptoms, 103 (61%) had symptom resolution, whereas 66 (39.1%) reported persistent symptoms. Among 34 patients without baseline OAB symptoms, 6% developed de novo symptoms. Older age was found to be a significant risk factor for persistence of symptoms postoperatively both on univariate (odds ratio, 0.97; 95% confidence interval, 0.94-1; P = 0.038) and multivariate logistic regression (odds ratio, 0.96, 95% confidence interval, 0.92-1; P = 0.049). The rate of medication discontinuation postoperatively was 25%. CONCLUSIONS: Approximately 61% of patients undergoing POP surgery had resolution of OAB symptoms postoperatively whether or not an incontinence procedure was performed. Older age was significantly related to persistent OAB symptoms in both univariate (P = 0.038) and multivariate (P = 0.049) models. The rate of de novo OAB symptoms was 6%.

Use of Surgery for Post-Prostatectomy Incontinence.

PURPOSE: Stress urinary incontinence following radical prostatectomy is common and potentially debilitating. Surgical therapy with a urethral sling or an artificial urinary sphincter is an effective option with high patient satisfaction in men in whom conservative measures fail to treat post-prostatectomy incontinence. We sought to characterize the contemporary utilization of surgical therapy of post-prostatectomy incontinence using an all payer database. MATERIALS AND METHODS: We used the Healthcare Cost and Utilization Project databases for Florida from 2006 to 2015 and identified men who underwent radical prostatectomy between 2006 and 2012 using ICD procedure codes. Patients were tracked longitudinally for placement of an ambulatory or inpatient urethral sling, or an artificial urinary sphincter between 2006 and 2015. Patient and clinical data were extracted and analyzed with descriptive statistics. A multivariable logistic regression model was constructed to determine risk adjusted predictors of subsequent incontinence surgery. RESULTS: During the study period 29,287 men underwent radical prostatectomy, of whom 1,068 (3.6%) were treated with subsequent incontinence surgery a median of 23.5 months after prostatectomy. On multivariate analysis risk factors for incontinence surgery included age groups 61 to 70 years (OR 1.25, p=0.008) and 71 to 80 years (OR 1.34, p=0.022), Medicare insurance (OR 1.33, p <0.005) and an increased Charlson Comorbidity Index (OR 1.13 per unit increase, p <0.005). CONCLUSIONS: Of patients who underwent radical prostatectomy 3.6% subsequently underwent stress urinary incontinence surgery. Post-prostatectomy incontinence surgery is likely under performed and delayed in performance based on the previously reported prevalence of severe post-prostatectomy incontinence and the natural history of symptoms. Efforts to increase prompt repair of refractory or severe incontinence can greatly improve patient quality of life after radical prostatectomy.

Risk Factors for Incomplete Bladder Emptying After Prolapse Repairs and Slings.

OBJECTIVE: The aim of this study was to determine the risk factors for catheter use and incomplete bladder emptying (IE) more than 1 week after prolapse repairs and slings. METHODS: This is a case-control study of women with prolapse repairs and/or sling from June 2011 to April 2016. All underwent standardized postoperative voiding trial before discharge. Controls and cases of IE were identified by codes and chart review; cases were defined as those needing any postoperative catheterization. We excluded patients with preoperative catheter use or postvoid residual (PVR) greater than 150 mL and those needing postoperative catheterization for reasons other than IE. Univariate and multivariate analyses were performed. RESULTS: A total of 475 (30.6%) cases and 478 controls were identified from 1552 eligible patients. Any catheter use was associated with higher uroflow PVR (71.2 vs 54.1 mL, P = 0.006), lower uroflow maximum flow (19.4 vs 25.4 mL/s, P < 0.001), and less detrusor overactivity (DO) (22.0% vs 28.7%, P = 0.03). Seventy-seven (5.0%) patients used catheters more than 1 week, and 15 patients (1.5%) required sling revision.Factors on multivariate analysis associated with any catheter use include office PVR [odds ratio (OR), 1.004; 1.00-1.008], uroflow maximum flow (OR, 0.96; 0.94-0.98), sling (OR, 2.40; 1.51-3.81), and anterior repair (OR, 1.81; 1.15-2.85). Factors associated with IE more than 1 week include uroflow maximum flow (OR, 0.90; 0.84-0.95), DO (OR, 0.21; 0.05-0.83), sling (OR, 3.68; 1.32-10.20), and uterosacral suspensions (OR, 3.43; 1.23-9.54). CONCLUSIONS: Overall, the incidence of short-term catheter use was 31%, prolonged IE more than 1 week was 5%, and 1.5% required sling revision. Sling placement, lower maximum flow, and higher preoperative PVR, anterior repair, and uterosacral ligament suspension are risk factors for IE, and presence of DO is protective.

Low Serum Albumin Correlates With Adverse Events Following Surgery for Male Urinary Incontinence: Analysis of the American College of Surgeons National Surgical Quality Improvement Project.

OBJECTIVE: To investigate the incidence and risk factors associated with artificial urinary sphincter (AUS) and male urethral sling placement (MUS), revision, and removal. METHODS: We identified CPT codes of patients undergoing AUS and sling placement, revision, and removal in the American College of Surgeons National Surgery Quality Improvement Program database. Bivariate analysis was used to compare preoperative parameters against adverse events of interest (Length of stay (LOS) >1, readmission, reoperation, other postoperative complications, and death). Variables that were significant or neared significance (P <.1) in the univariate analysis were entered into multivariable logistic regression models. Multivariable models were used to estimate the probability of adverse events. RESULTS: About 2792 patients underwent surgical treatment for stress urinary incontinence in the American College of Surgeons National Surgery Quality Improvement Program database from 2008 to 2016. Increased length of stay was the most common adverse event (12.7%), followed by other postoperative complications (4.9%), readmission (4%), reoperation (2.3%), and death (0.3%). We noted an association between perioperative adverse events and preoperative hypoalbuminemia. Patients with preoperative hypoalbuminemia compared with patients with normal preoperative serum albumin had an increase predicted probability of LOS >1 day (42% vs 10%), readmission (10% vs 4%), reoperation (6% vs 2%), other postoperative complications (18% vs 4%) after adjusting for other factors. CONCLUSION: Surgical treatment for stress urinary incontinence is well tolerated with acceptable levels of perioperative adverse events. Low serum albumin (<3.5 ng/dL) was associated with perioperative adverse events. These data may affect preoperative decision making and direct future quality improve efforts at the highest risk patients to help minimize perioperative morbidity and mortality.

Reoperation for Urinary Incontinence After Retropubic and Transobturator Sling Procedures.

OBJECTIVE: To compare the reoperation rates for recurrent stress urinary incontinence (SUI) after retropubic and transobturator sling procedures. METHODS: We conducted a retrospective cohort study of all women who underwent midurethral sling procedures at a single institution for primary SUI between 2002 and 2012. To minimize bias, women in the two groups were matched on age, body mass index, isolated compared with combined procedure, and preoperative diagnosis. The primary outcome was defined as reoperation for recurrent SUI. Secondary outcomes included intraoperative complications and mesh-related complications requiring reoperation after the index sling procedure. RESULTS: We identified 1,881 women who underwent a sling procedure for primary SUI-1,551 retropubic and 330 transobturator. There was no difference between groups in any of the evaluated baseline variables in the covariate-matched cohort of 570 with retropubic slings and 317 with transobturator slings; results herein are based on the covariate-matched cohort. Women undergoing a transobturator sling procedure had an increased risk of reoperation for recurrent SUI compared with women undergoing a retropubic sling procedure (hazard ratio 2.42, 95% CI 1.37-4.29). The cumulative incidence of reoperation for recurrent SUI by 8 years was 5.2% (95% CI 3.0-7.4%) in the retropubic group and 11.2% (95% CI 6.4-15.8%) in the transobturator group. Women in the retropubic group had a significantly higher rate of intraoperative complications compared with women in the transobturator group (13.7% [78/570] vs 4.7% [15/317]; difference=9.0%, 95% CI for difference 5.3-12.6%); the majority of this difference was due to bladder perforation (7.0% [40/570] vs 0.6% [2/317]; difference=6.4%, 95% CI for difference 4.1-8.7%). The cumulative incidence of sling revision for urinary retention plateaued at 3.2% and 0.4% by 5 years in the two groups. CONCLUSION: Women with primary SUI treated with a retropubic sling procedure have significantly lower cumulative incidence of reoperation for recurrent SUI compared with women who were treated with a transobturator sling procedure. Retropubic slings were associated with a higher risk of sling revision for urinary retention.

Occult Urinary Incontinence Treatment: Systematic Review and Meta-analysis-Brazilian Guidelines.

OBJECTIVE: To evaluate if performing anti-incontinence procedures during surgical anterior and/or apical prolapse correction in women with asymptomatic urinary incontinence (UI) may prevent stress urinary incontinence (SUI) postoperatively. METHODS: We have performed a systematic review of articles published in the PubMed, Cochrane Library, and Lilacs databases until March 31, 2016. Two reviewers performed the data collection and analysis, independently. All of the selected studies were methodologically analyzed. The results are presented as relative risk (RR), with a 95% confidence interval (CI). RESULTS: After performing the selection of the studies, only nine trials fulfilled the necessary prerequisites. In the present review, 1,146 patients were included. Altogether, the review included trials of three different types of anti-incontinence procedures. We found that performing any anti-incontinence procedure at the same time of prolapse repair reduced the incidence of SUI postoperatively (RR = 0.50; 95% CI: 0.28-0.91). However, when we performed the analysis separately by the type of anti-incontinence procedure, we found different results. In the subgroup analysis with midurethral slings, it is beneficial to perform it to reduce the incidence of SUI (RR = 0.08; 95% CI: 0.02-0.28). On the other hand, in the subgroup analysis with Burch colposuspension, there was no significant difference with the control group (RR = 1.47; 95% CI: 0.28-7.79]). CONCLUSION: Performing any prophylactic anti-incontinence procedure at the same time as prolapse repair reduced the incidence of SUI postoperatively. The Burch colposuspension did not show any decrease in the incidence of SUI postoperatively.

OBJETIVO: Avaliar se a realização de procedimentos anti-incontinência durante a correção cirúrgica do prolapso anterior e/ou apical em mulheres assintomáticas para incontinência urinária (IU) pode prevenir a incontinência urinária de esforço (IUE) no pós-operatório. MéTODOS:: Foi realizada uma revisão sistemática dos artigos publicados nas bases de dados PubMed, Cochrane Library e Lilacs até o dia 31 de março de 2016. Dois revisores realizaram a coleta e a análise de dados, de forma independente. Todos os estudos selecionados foram analisados metodologicamente. Os resultados estão apresentados como risco relativo (RR), com 95% de intervalo de confiança (IC). RESULTADOS: Após a seleção do estudo, apenas nove estudos preencheram os pré-requisitos necessários. Nesta revisão, 1.146 pacientes foram incluídos. No total, a revisão incluiu ensaios de três tipos diferentes de procedimentos anti-incontinência. Descobrimos que realizar qualquer procedimento anti-incontinência ao mesmo tempo que o reparo do prolapso reduziu a incidência de IU no pós-operatório (RR = 0,50; IC 95%: 0,28­0,91). No entanto, quando fizemos a análise separadamente pelo tipo de procedimento anti-incontinência, encontramos resultados diferentes. Na análise de subgrupos com slings miduretrais, é benéfico realizá-lo para reduzir a incidência de IU (RR = 0,08; IC 95%: 0,02­0,28). Por outro lado, na análise de subgrupo com colposuspensão de Burch, não houve diferença significativa com o grupo controle (RR = 1,47; IC 95%: 0,28­7,79]). CONCLUSãO:: A realização de qualquer procedimento profilático anti-incontinência ao mesmo tempo que o reparo do prolapso reduziu a incidência de IUE no pós-operatório. A colposuspensão de Burch não mostrou diminuição na incidência de IUE no pós-operatório.

Utility of Preoperative Laboratory Testing in Women Undergoing Suburethral Sling.

OBJECTIVE: The aim of the study was to examine current patterns and factors associated with preoperative testing in patients undergoing midurethral sling and to compare 30-day outcomes in subjects. METHODS: This retrospective cohort study was performed using the National Surgery Quality Improvement Program database from 2005 to 2014. All women undergoing midurethral slings were identified by Current Procedural Terminology code. Clinical variables were abstracted and the incidence of preoperative serum labs was determined. Multivariable logistic regression was used to estimate associations between clinical factors and collection of preoperative serum labs and between 30-day outcomes and collection of labs. RESULTS: A total of 12,368 women underwent midurethral sling in the National Surgery Quality Improvement Program database during the study period. Preoperative serum testing within 30 days before surgery was observed in 9172 (74.2%) women. Age, American Society of Anesthesiologists class, diabetes, and hypertension were strongly associated with preoperative testing when modeling together in multivariable regression. Of the 543 women who had any complication, 410 (75.5%) received preoperative testing. Urinary tract infection was the most frequent complication (66.1%). Age, American Society of Anesthesiologists class, body mass index, and presence of any comorbidity were associated with the presence of any complication at 30 days. Adjusting for these factors, the odds of complications were not significantly different between those who did and did not have preoperative testing (adjusted odds ratio = 0.98, 95% confidence interval = 0.78-1.24). CONCLUSIONS: Most women who underwent midurethral sling procedures had preoperative testing. Major postoperative complications were uncommon, and there was no substantial difference in outcomes between women who underwent preoperative testing and those who did not. In the future, surgeons may consider eliminating preoperative testing in low-risk patients.