One and five-year efficacy of tension-free vaginal tape (TVT) abbrevo and TVT-obturator in the treatment of stress urinary incontinence: a retrospective study.

BACKGROUND: Surgical interventions are more effective than nonsurgical approaches in providing a cure for stress urinary incontinence (SUI). In this study, we aimed to assess the benefits of tension-free vaginal tape (TVT) abbrevo by comparing its efficacy and complications to those of TVT obturator. METHODS AND RESULTS: 49 and 47 patients at The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University between January 2013 and December 2016 were included in the TVT-O and TVT-A groups, respectively. We evaluate the success rate and perioperative complications associated with TVT-O and TVT-A. A questionnaire that utilized the Patient Global Impression of Improvement (PGI-I) Scale was employed to assess the impact of surgery. Patients were followed up at 1 year, and 5 years after surgery. There were no statistically significant differences found in the efficacy of the TVT-A group and TVT-O group during both the one-year (p = 0.4) and five-year (p = 0.32) follow-up periods. In the period of one-year follow-up, 95.9% (n = 47) of patients in the TVT-O group and 95.8% (n = 45) of patients in the TVT-A group demonstrated improvement. During the period of five-year follow-up, 87.8% (n = 43) of patients in the TVT-O group and 93.6% (n = 44) of patients in the TVT-A group demonstrated improvement. CONCLUSIONS: Based on our findings, TVT-A and TVT-O procedures exhibited similarly high success rates and low frequencies of complications.

Early experience and future prospects regarding use of newly developed surgical robot system, hinotori, in the field of urologic cancer surgery.

In the field of urology, robotic surgery has gained rapid and wide acceptance as a standard surgical approach in the majority of major surgeries over the last decade. To date, the da Vinci surgical system has been the dominant platform in robotic surgery; however, several newly developed robotic systems have recently been introduced in routine clinical practice. Of these, hinotori, the first made-in-Japan robotic system, is characterized by various unique and attractive features different from the existing system, and the use of this system has gradually increased mainly in urologic cancer surgeries, including radical prostatectomy, partial nephrectomy, radical nephrectomy, and radical nephroureterectomy. This review initially describes detailed characteristics of hinotori, then summarizes the early experience with urologic cancer surgeries using hinotori at our institution, and finally discusses the future prospects of robotic surgery using hinotori, considering problems associated with the use of this robotic system.

Assessing the Feasibility and Safety of the Toumai® Robotic System in Urologic Surgery: Initial Experience.

Introduction: Robotic surgery using da Vinci surgical system has gained prominence in urology; emerging robotic platforms are expanding its applications and increasing affordability. We assess the feasibility and safety of a novel system, the Toumai® robotic system in various urological surgeries. Methods: This prospective study was conducted at the first affiliated hospital of Zhengzhou university. Twenty consecutive patients underwent renal and prostatic surgery with the Toumai. The study assessed technical feasibility (conversion rate) and safety (perioperative complications) of the procedures as primary outcomes. Secondary endpoints included key surgical perioperative outcomes: functional and oncologic results. The Endoscopic Surgical System operates within a master-slave protocol, comprising a Surgeon Console, Patient Platform, and Vision Platform. Results: Seventeen patients underwent various nephrectomy procedures and three underwent radical prostatectomy (RP). There was no conversion to alternative surgical approach; a single (Clavien-Dindo grade ≥3b) complication occurred, and no readmission was recorded within 30 days. The median operative time was 120, 140, and 210 minutes for partial nephrectomy (PN), radical nephrectomy, and RP, respectively. Off-clamp PN was performed in one case, and the warm ischemia time in the remaining two case was 18 minutes. The median docking time was 22 minutes for nephrectomy and 20 minutes for RP; no major robotic malfunction was encountered. At 3-month follow-up, no tumor recurrence was recorded, renal function was well preserved, and the continence status was satisfactory. Conclusions: We present the initial clinical utilization of an innovative robotic platform. Complex urological surgeries were successfully completed without conversions and with minimal complications. Further investigations are warranted to confirm these initial findings.

Laparoscopic renal surgery using multi degree-of-freedom articulating laparoscopic instruments in a porcine model.

PURPOSE: We evaluated the performance of a new multi-degree-of-freedom articulating laparoscopic instrument, ArtiSential, and compared it with that of a straight-shaped instrument and the da Vinci surgical system, in renal surgery using porcine model. MATERIALS AND METHODS: Nine female Yorkshire pigs were equally divided into three groups. The three groups were compared at each surgical step in terms of objective and subjective parameters. RESULTS: The median operative times for renal pedicle clamping and ureter dissection were significantly shorter in ArtiSential group than robotic group (1.3 min vs. 4.7 min, p=0.002; 8.1 min vs. 11.1 min, p=0.015). The median operative time for bladder repair was significantly longer in ArtiSential group than robotic and straight-shaped groups (17.9 min vs. 5.5 min, p=0.002; 17.9 min vs. 9.3 min, p=0.026). There were no significant differences among groups in terms of blood loss or intraoperative complications. ArtiSential device was less useable for renorrhaphy (p=0.009) and bladder repair (p=0.002) compared to the robotic system. ArtiSential group was less accurate than robotic group in terms of tumor resection, renorrhaphy, and bladder repair. During ureter dissection, bladder cuff excision, and bladder repair, the surgeon experienced greater wrist discomfort but lesser back discomfort in ArtiSential group than robotic group. CONCLUSIONS: For most steps, ArtiSential performed as well as robotic and straight-shaped instruments. The development of specialized surgical techniques for ArtiSential will maximize the advantages of these instruments.

Reoperation for Channel Complications in Children With Continent Cutaneous Catheterizable Channels: The Test of Time.

OBJECTIVES: To examine the durability of continent cutaneous catheterizable urinary channels (CCCC) in children and assess whether channel complications continue to arise with extended follow-up. Previous studies demonstrated that complications of CCCC cluster in the early years following surgery. METHODS: The database of a tertiary center was queried for patients≤21 years who underwent CCCC. Patients with <6 years of follow-up were excluded. Patients were invited for follow-up to assess continence. Clinic visits and hospital admissions were reviewed for channel complications requiring reoperation. Complications were analyzed against patient and channel characteristics and time since initial surgery. RESULTS: Between 1993 and 2012, a total of 120 patients underwent CCCC at a median age of 6.8(0.4-21) years and a median follow-up of 11.4(6.6-27) years. CCCC were created using the appendix, Monti channels and tapered ileal segments in 74(61.7%), 33(27.5%) and 13(10.8%), respectively. Continence relied on the extra-mural serous lined principle in 85.8% and the stoma was anastomosed to the umbilicus in 90%. Dryness with catheterization intervals of 3 hours or longer was eventually achieved in 90.8% with similar rates among different channel types (P=.149). 26(21.7%) required 42 interventions to treat channel complications with 32.5% occurring >5 years following initial surgery irrespective of the channel type (P=.978). On multivariate analysis, ileal channels had 3.372 higher odds of needing reoperation compared to appendicovesicostomy (95%CI=1.240-9.166; P = .037). CONCLUSION: A high reoperation rate is anticipated throughout the lifetime of CCCC. Appendicovesicostomy has a low complication risk relative to ileal channels.

Symptom Resolution and Recurrent Urinary Incontinence Following Removal of Painful Midurethral Slings.

OBJECTIVE: To evaluate pain improvement and recurrent stress incontinence (SUI) following painful synthetic midurethral sling (MUS) removal. METHODS: We conducted a retrospective review of patients who underwent synthetic MUS removal at our institution from 2009-2016 for the indication of pain. We recorded sling type (transobturator vs retropubic), complete vs partial removal, and presenting symptoms. Postoperative pain improvement was categorized as resolved (pain resolved, requiring no further therapy), improved (pain less bothersome, may require further therapy), or unresolved (no/minimal improvement, requiring further management). Recurrent incontinence and further reconstructive procedures were assessed. RESULTS: 87 patients (49 complete and 38 partial removal) with pain as the primary indication for removal were included. Median age at intervention was 54 years with median follow-up of 8 months. Overall, pain improved or resolved in 78.1% of cases. Complete removal was associated with significantly greater percentage of pain resolution (63.3%) compared to partial removal (26.3%) (P = 0.002) regardless of sling type. No significant differences in recurrent SUI were noted in complete vs partial removal. Additional reconstructive procedures were performed in 28 patients, most commonly sling placement, with no significant difference in complete (20.4%) vs partial (28.9%) removal groups (P = 0.36). The overall complication rate was low (5.7%), a majority of which were transfusions (4.6%). CONCLUSION: Following MUS removal, most patients experienced resolution or improvement of pain. Complete sling removal was associated with significantly greater percentage of pain resolution compared to partial removal in both retropubic and transobturator slings. Rates of recurrent SUI and reintervention for SUI were not related to the extent of sling removal.

Future Platforms of Robotic Surgery.

Among the various robotic devices that exist for urologic surgery, the most common are synergistic telemanipulator systems. Several have achieved clinical feasibility and have been licensed for use in humans: the standard da Vinci, Avatera, Hinotori, Revo-i, Senhance, Versius, and Surgenius. Handheld and hands-on synergistic systems are also clinically relevant for use in urologic surgeries, including minimally invasive and endoscopic approaches. Future trends of robotic innovation include an exploration of more robust haptic systems that offer kinesthetic and tactile feedback; miniaturization and microrobotics; enhanced visual feedback with greater magnification and higher fidelity detail; and autonomous robots.

Host-biomaterial interactions in mesh complications after pelvic floor reconstructive surgery.

Polypropylene (PPL) mesh is widely used in pelvic floor reconstructive surgery for prolapse and stress urinary incontinence. However, some women, particularly those treated using transvaginal PPL mesh placement for prolapse, experience intractable pain and mesh exposure or extrusion. Explanted tissue from patients with complications following transvaginal implantation of mesh is typified by a dense fibrous capsule with an immune cell-rich infiltrate, suggesting that the host immune response has a role in transvaginal PPL mesh complications through the separate contributions of the host (patient), the biological niche within which the material is implanted and biomaterial properties of the mesh. This immune response might be strongly influenced by both the baseline inflammatory status of the patient, surgical technique and experience, and the unique hormonal, immune and microbial tissue niche of the vagina. Mesh porosity, surface area and stiffness also might have an effect on the immune and tissue response to transvaginal mesh placement. Thus, a regulatory pathway is needed for mesh development that recognizes the roles of host and biological factors in driving the immune response to mesh, as well as mandatory mesh registries and the longitudinal surveillance of patients.

Narrow Vagina as a Predictor of Obstructive Voiding Dysfunction after Transobturator Sling Surgery.

BACKGROUND: Voiding dysfunction (VD) is a potential complication after female midurethral sling operations. OBJECTIVES: Our goal was to assess the rate of obstructive VD after -transobturator tension-free tape (TOT) procedures and to find perioperative risk factors (RFs) predicting postoperative voiding problems. METHODS: We have retrospectively evaluated the perioperative data of 397 women who underwent TOT operations. Significant post-void residual (PVR) (>50 mL) was considered as the primary (objective) end point of the study, the voiding difficulty as the secondary (subjective) 1. First univariate analysis and then multivariate logistic regression were performed, with a 5% significance level. RESULTS: Significant PVR was present in 51 (12.8%) women; catheterization was needed in 21 (5.3%) and reoperation in 3 (0.8%) cases. Seventy women (17.6%) experienced postoperative voiding difficulty. Narrow vagina (<2 cm), older age >70 years, and preoperative voiding difficulty were independent RFs for significant PVR (odds ratio: 5.07, 2.14, 5.38, respectively, p < 0.05). Preoperative overactive bladder syndrome and previous pelvic organ prolapse surgery were considered independent RFs for postoperative voiding difficulty. CONCLUSIONS: Older age, narrow vagina, or preoperative voiding difficulty increases the chance for significant postoperative PVR. These patients should be chosen and counseled appropriately.

Cure of Interstitial Cystitis and Non-Ulcerating Hunner's Ulcer by Cardinal/Uterosacral Ligament Repair.

A serendipitous cure in a 73-year-old woman of Hunner's ulcer, urge, nocturia, apical prolapse by a tissue fixation system tensioned minisling (TFS) which reinforced the cardinal, and uterosacral ligaments (USLs) led us to analyse the relationship between Hunner's ulcer and known pain conditions associated with USL laxity. The original intention was to cure the "posterior fornix syndrome" (PFS), uterine prolapse, and associated pain and bladder symptoms by USL repair. A speculum inserted preoperatively into the posterior fornix alleviated pain and urge symptoms, by mechanically supporting USLs. Hunner's ulcer, along with pain and other PFS symptoms were cured by USL repair. The concept of USL laxity causing chronic pelvic pain and bladder problems is not new. It was published in the German literature by Heinrich Martius in 1938 and by Petros in the English literature in 1993. These findings raise important questions. As PFS symptoms are identical with those of interstitial cystitis (IC), are PFS and IC similar conditions? If so, then patients with IC who have a positive speculum test are at least theoretically, potentially curable by USL repair. These questions need to be explored.

Impact of Autologous Transobturator Sling Surgery on Female Sexual Function: A Comparative Study with Mesh Used Mid-Urethral Sling Surgeries.

INTRODUCTION: To avoid mesh-related complications, autologous transobturator-tape (a-TOT) technique is a viable option in stress urinary incontinence (SUI) surgery. The method differs from TOT and retropubic tape (RT) in the usage of autologous tissue. We hypothesized that a-TOT improves female sexual dysfunction (FSD) more than TOT and RT. METHODS: This is a retrospective cohort study. Patients who underwent a-TOT, TOT, and RT surgeries were surveyed regarding the cure of SUI, complications, and FSD parameters. The groups were compared according to baseline and postoperative data. RESULTS: A-TOT, TOT, and RT groups included 37, 69, and 36 patients, respectively. The median follow-up time was 19 months. The groups were similar in terms of preoperative characteristics. The objective cure, subjective cure, and overall complication rates were comparable among the groups (p > 0.05). A-TOT group had significant improvements in mean female sexual function index (FSFI) scores, TOT group deteriorated, and RT group remained stable (p = 0.001, p = 0.001, and p = 0.226, respectively). The postoperative mean total FSFI scores were 25.73 ± 2.46, 23.17 ± 3.35, and 21.53 ± 2.47 for the a-TOT, TOT, and RT groups, respectively. The a-TOT group had better results than the TOT and RT groups (p < 0.05 and p < 0.05), and besides, the difference between the TOT and RT groups was statistically significant (p < 0.05). According to percentage changes in domain scores following the operations, the a-TOT group had significantly better results in desire, arousal, lubrication, satisfaction, and pain domains than the TOT group (p < 0.05) as well as better desire, arousal, and pain domains (p < 0.05) than the RT group. DISCUSSION/CONCLUSIONS: Besides comparable outcomes in SUI treatment, the a-TOT technique provides improvements in female sexual functions while TOT worsens and RT does not change. Favorable outcomes in sexual functions caused by improvements in desire, arousal, satisfaction, and pain domains are observed following the a-TOT technique.

Novel Use of a Modified Triangular Prismatic Double-J Stent for 2- to 3-cm Renal Stones after One-Stage Retrograde Intrarenal Surgery.

OBJECTIVES: To initially evaluate the outcomes of the modified triangular prismatic double-J (DJ) stent in the management of 2- to 3-cm renal stones after one-stage retrograde intrarenal surgery (RIRS). METHODS: Patients with 2- to 3-cm renal stones who underwent one-stage RIRS with indwelling DJ stents were retrospectively evaluated. Eighty-eight patients who were placed the triangular prismatic DJ stents and 64 patients who received standard DJ stents were randomly included. The clinical characteristics and intraoperative and postoperative outcomes of the 2 groups were compared and analyzed. RESULTS: The 2 groups had similar baseline characteristics. The urinary symptom score and pain score did not differ between groups (p > 0.05). The residual fragments of the 2 groups were similar 1 day after operation (p = 0.134). There was no significant difference in residual fragments in the lower calyx between groups at the time of stent removal (p = 0.834). The patients in the modified group had better spontaneous passage of residual fragments in the nonlower calyx than those in the standard group during the 2 weeks with the stents (p = 0.005). Fewer patients in the modified group had residual fragments (>4 mm) in the nonlower calyx (p = 0.026) and ureter (p = 0.010) than the patients with standard stents at the time of stent removal. CONCLUSION: The indwelling triangular prismatic DJ stent is a safe and efficient treatment method. Patients with these stents had better spontaneous residual fragment passage than those with the standard DJ stents.

Single Port Robotic Surgery in Urology.

PURPOSE: To provide a comprehensive review on the new da Vinci SP (single port) robotic surgical system. The published literature to date within urology and a description of the new system will be discussed. FINDINGS: There are currently no high-quality published studies with the SP robotic system. All studies are case series, many with 10 or fewer patients. However, all studies have found the SP system to be safe and feasible in performing most urological procedures. Renal and pelvic surgery using the SP robotic system is safe and feasible in the hands of expert robotic surgeons. Long-term, high-quality data is lacking. While the current high price and the learning curve will limit the SP systems' use in many health care systems, new updates and the release of robotic surgical systems from other developers may help drive down costs and encourage uptake.

Robotic surgical systems in urology: What is currently available?

Robotic assistance in laparoscopic surgery was introduced at the turn of this millennium, marking a milestone in the history of surgery. Urologists were early adopters of robotic technology and the indications of robot-assisted surgery in urology are expanding. Over the last 20 years, the da Vinci surgical system was the dominant system in the robotic surgical market. However, the recent expiration of Intuitive patents has allowed new systems to enter the market more freely. We performed a nonsystematic literature review using the PubMed/MEDLINE search engines. The aim of this review was to briefly summarize the currently available robotic surgical systems for laparoscopic urologic surgery. New surgical devices have already been launched in the robotic market and the da Vinci systems have some competition. The innovation of robotic technology is continuing, and new features such as an open-console design, haptic feedback, smaller instruments, and separately mounted robotic arms have been introduced. A new robotic era is rising, and new systems and technologies enhancing patient care are welcomed.

Treat or Wait? Natural Perioperative Course of Overactive Bladder Symptoms at the Time of Midurethral Sling Placement.

OBJECTIVE: The aims of this study were to describe the perioperative course of untreated overactive bladder (OAB) (urinary frequency [UF] and urgency urinary incontinence [UUI]) before and after isolated retropubic midurethral sling (MUS) and to identify the time point for spontaneous OAB symptom improvement in the most patients. METHODS: This is a prospective cohort study of women undergoing an isolated MUS. Women completed the Urogenital Distress Inventory 6 and Incontinence Impact Questionnaire 7 preoperatively and weekly for 13 weeks postoperatively. Bothersome UF and UUI were defined as a response of "moderately" or "greatly" bothered on questions 1 and 2 of the Urogenital Distress Inventory. The treatment for OAB was deferred until 13 weeks after surgery. RESULTS: Fifty-four women were included with a mean ± SD age of 48 ± 9 years. Preoperatively, 41% of women reported both bothersome UF and UUI. Six weeks after surgery, only 15% and 6% reported bothersome UF and UUI (P < 0.001 and P < 0.001, respectively). Between 6 and 13 weeks, percentages of bothersome symptoms remained low (11.7% UF and 5.8% UUI). In addition, the impact of these urinary symptoms on activities, relationships, and feelings became consistently negligible (Incontinence Impact Questionnaire 7 median score <1) at 5 weeks postoperatively. Only 3 women desired treatment for UUI after the study period. CONCLUSIONS: Overactive bladder is common before and immediately after MUS. However, the majority of patients have spontaneous symptom resolution by 6 weeks after surgery; it may be reasonable to discontinue preoperatively initiated overactive bladder treatment or defer starting treatment until this time point.

A Multicenter Prospective Study Evaluating Efficacy and Safety of a Single-incision Sling Procedure for Stress Urinary Incontinence.

STUDY OBJECTIVE: The aim of the Altis 522 study was to compare the safety and efficacy of the Altis Single-Incision Sling System (SIS) (Coloplast, Minneapolis, MN) with standard midurethral transobturator and/or retropubic slings through 36 months. In this report, we present data through 12 months of follow-up. DESIGN: Postmarket, prospective, multicenter, nonrandomized cohort design. SETTING: The study was performed at 23 hospitals in the United States and Canada. PATIENTS: Adult female patients with stress urinary incontinence (SUI) clinically indicated for an incontinence sling were treated (n = 355). INTERVENTIONS: Altis SIS was compared with any Food and Drug Administration-cleared transobturator or retropubic sling. MEASUREMENTS AND MAIN RESULTS: Collected measures included device- and/or procedure-related serious adverse events, relevant nonserious and all adverse events, and revision surgery. Objective efficacy measures included 24-hour pad weight, dryness (defined as pad weight ≤4.0 g), and cough stress test. Subjective outcome measures included patient global impression of improvement, urogenital distress inventory, Incontinence Impact Questionnaire-Short Form, Surgical Satisfaction Questionnaire, and visual analog scale for pain. At 12 months, 24-hour pad weight success (≥50% reduction), negative cough stress test, patient global impression of improvement, urogenital distress inventory, and Incontinence Impact Questionnaire-Short Form appeared similar between groups. Through 12 months, 2 subjects in the Altis group and 3 subjects in the comparator group experienced a serious device- and/or procedure-related adverse event. In the Altis group, 1 subject (0.5%) experienced a device revision, and 1 subject (0.5%) had the device explanted. In the comparator group, 7 subjects (4.1%) experienced a device revision, and 1 device (0.6%) was explanted before the 12-month visit. The occurrence of relevant nonserious procedure and/or device-related adverse events was similar between groups. CONCLUSION: At 12-months follow-up, safety and efficacy appeared similar between Altis SIS and standard transobturator and retropubic midurethral slings.