Long-term Rate of Mesh Sling Removal Following Midurethral Mesh Sling Insertion Among Women With Stress Urinary Incontinence.

Importance: There is concern about outcomes of midurethral mesh sling insertion for women with stress urinary incontinence. However, there is little evidence on long-term outcomes. Objective: To examine long-term mesh removal and reoperation rates in women who had a midurethral mesh sling insertion for stress urinary incontinence. Design, Setting, and Participants: This population-based retrospective cohort study included 95 057 women aged 18 years or older who had a first-ever midurethral mesh sling insertion for stress urinary incontinence in the National Health Service hospitals in England between April 1, 2006, and December 31, 2015. Women were followed up until April 1, 2016. Exposures: Patient and hospital factors and retropubic or transobturator mesh sling insertions. Main Outcomes and Measures: The primary outcome was the risk of midurethral mesh sling removal (partial or total) and secondary outcomes were reoperation for stress urinary incontinence and any reoperation including mesh removal, calculated with death as competing risk. A multivariable Fine-Gray model was used to calculate subdistribution hazard ratios as estimates of relative risk. Results: The study population consisted of 95 057 women (median age, 51 years; interquartile range, 44-61 years) with first midurethral mesh sling insertion, including 60 194 with retropubic insertion and 34 863 with transobturator insertion. The median follow-up time was 5.5 years (interquartile range, 3.2-7.5 years). The rate of midurethral mesh sling removal was 1.4% (95% CI, 1.3%-1.4%) at 1 year, 2.7% (95% CI, 2.6%-2.8%) at 5 years, and 3.3% (95% CI, 3.2%-3.4%) at 9 years. Risk of removal declined with age. The 9-year removal risk after transobturator insertion (2.7% [95% CI, 2.4%-2.9%]) was lower than the risk after retropubic insertion (3.6% [95% CI, 3.5%-3.8%]; subdistribution hazard ratio, 0.72 [95% CI, 0.62-0.84]). The rate of reoperation for stress urinary incontinence was 1.3% (95% CI, 1.3%-1.4%) at 1 year, 3.5% (95% CI, 3.4%-3.6%) at 5 years, and 4.5% (95% CI, 4.3%-4.7%) at 9 years. The rate of any reoperation, including mesh removal, was 2.6% (95% CI, 2.5%-2.7%) at 1 year, 5.5% (95% CI, 5.4%-5.7%) at 5 years, and 6.9% (95% CI, 6.7%-7.1%) at 9 years. Conclusions and Relevance: Among women undergoing midurethral mesh sling insertion, the rate of mesh sling removal at 9 years was estimated as 3.3%. These findings may guide women and their surgeons when making decisions about surgical treatment of stress urinary incontinence.

Minimum standards for continence care in the UK.

AIM: This paper reports on the publication of a joint statement on minimum standards for continence care in the UK. METHODS: A multidisciplinary working party were tasked with creating standards for both training and education in continence care, as well as explicit standards for a framework of service delivery. This was done through a process of extensive consultation with relevant professional bodies. RESULTS: The standards suggest a modular structure to continence training, including basic, male, female, catheter care etc. Discussions on service provision cover primary care through to expert tertiary centres. CONCLUSIONS: This is the first attempt to standardise continence care and training for all health care professionals nationally. The document is available on the United Kingdom Continence Society website www.ukcs.uk.net.

Pelvic floor muscle training as an adjunct to prolapse surgery: a randomised feasibility study.

INTRODUCTION AND HYPOTHESIS: There is evidence that in nonsurgical populations, pelvic floor muscle training (PFMT) and lifestyle advice improves symptoms and stage of pelvic organ prolapse (POP). Some women, however, require surgery, after which de novo symptoms can develop or additional surgery is required due to recurrence. Robust evidence is required as to the benefit of perioperative PFMT in the postsurgery reduction of symptoms and POP recurrence. The aim of this study was to assess the feasibility of and collect pilot data to inform sample size (SS) calculation for a multicentre randomised controlled trial (RCT) of perioperative PFMT following surgical intervention for POP. METHODS: Fifty-seven participants were recruited and randomised to a treatment group (one pre and six postoperative PFMT sessions) or a control group (usual care). The primary outcome measure was the Pelvic Organ Prolapse Symptom Score (POP-SS) at 12 months; secondary outcome measures included measurement of prolapse, the pelvic floor and questionnaires relating to urinary and bowel incontinence. All outcomes were measured at 0, 6 and 12 months. RESULTS: Information on recruitment, retention and appropriateness of outcome measures for a definitive trial was gathered, and data enabled us to undertake an SS calculation. When compared with the control group (n = 29), benefits to the intervention group (n = 28) were observed in terms of fewer prolapse symptoms at 12 months [mean difference 3.94; 95 % confidence interval (CI) 1.35-6.75; t = 3.24, p = 0.006]; however, these results must be viewed with caution due to possible selection bias. CONCLUSION: With modifications to design identified in this pilot study, a multicentre RCT is feasible.

Minimum standards for urodynamic practice in the UK.

AIM: This paper reports on the recent publication and wide distribution of a joint statement on minimum standards for urodynamic practice in the UK. METHODS: A multidisciplinary working party were tasked with creating standards for both training and certification in urodynamics, as well as explicit standards for a framework of service delivery. This was done through a process of extensive consultation with relevant professional bodies. RESULTS: The standards suggest a modular structure to urodynamics training, and make recommendations on minimum workload for individuals and departments, the need for multidisciplinary team working and for regular audit. CONCLUSIONS: This is the first attempt to standardise urodynamics practice nationally. The document is available on the United Kingdom Continence Society websitewww.ukcs.uk.net.

Obstetric risk factors and pelvic floor dysfunction 20 years after first delivery.

INTRODUCTION AND HYPOTHESIS: Intrapartum events at first delivery and subsequent childbearing are associated with long-term pelvic floor dysfunction (PFD). METHODS: Primigravidae delivered between 1983-1986 were identified; current addresses traced through the UK National Health Service database (N = 3002). Women completed screening and Sheffield Pelvic Floor Questionnaires (Sheffield-PAQ). Maternity data were obtained from Standard Maternity Information System. Primary outcomes were urinary incontinence (UI), anal incontinence (AI), and prolapse (POP). RESULTS: Primary response was 62.1%; 53.8% (n = 985) had >or=1 PFD symptom and in 71.5% symptoms were bothersome. UI (OR 0.47 95% CI 0.28, 0.81) and fecal incontinence (FI; OR 0.32 95% CI 0.13, 0.77) risks were lower after first delivery by cesarean section (CS). However, 25% had UI and 12% had FI after delivering exclusively by CS. Obesity was a risk factor independent of obstetric history. CONCLUSIONS: CS provides incomplete or poorly sustained pelvic floor protection by middle age. Obese women were at highest risk and had the most severe symptoms.

RCT of urethral versus suprapubic catheterization.

OBJECTIVE: To compare the use of intermittent urethral catheterization with indwelling suprapubic catheterization in women undergoing surgery for urodynamic stress incontinence or uterovaginal prolapse. DESIGN: Randomized controlled trial. SETTING: Tertiary referral urogynaecology unit. POPULATION: Women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence. METHODS: Women were randomized into one of two groups. Group 1 had bladder drainage using a suprapubic catheter inserted in theatre. The catheter was left on free drainage for 48 hours post-operatively before clamping. Group 2 was catheterized intermittently post-operatively. MAIN OUTCOME MEASURES: Length of post-operative hospital stay: time to resume normal voiding (defined as voided volumes greater than 200 mls and residual urine volumes less than 100 mls on three occasions); number of urinary tract infections (UTIs); catheterization costs; patient experience (determined from questionnaire); and a pain score. RESULTS: 75 women were randomized; 38 to suprapubic catheterization; 37 to intermittent catheterization. Three were withdrawn from study, leaving 36 women in each group. Groups were closely matched for age and type of surgery undertaken. Length of hospital stay and total duration of catheterization were both significantly shorter for the intermittent catheterization group; although there was no difference in the rate of UTI between the two groups. There was no clear patient preference for a specific catheterization method. CONCLUSIONS: The use of intermittent catheterization following urogynaecological surgery is associated with a more rapid return to normal micturition and a shorter hospital stay, although the clinical significance of the difference is perhaps limited.

Randomized comparison of vaginal and rectal measurement of intra-abdominal pressure during subtracted dual-channel cystometry.

OBJECTIVES: To compare the rectal (Prec) and vaginal (Pvag) measurement of intra-abdominal pressure during cystometry in women by assessment of patient acceptability and cystometrogram quality control. METHODS: Of 136 consecutive women undergoing cystometrography, 100 were randomized to measurement of Prec or Pvag. The patients' experience was measured using visual analogue scales of anticipated and actual discomfort and embarrassment before and after the procedure. The setup time was recorded, and quality control was assessed by the number of catheter events (pressure lines falling out, requiring flushing, or repositioning), and quality of the cough signal. RESULTS: A total of 136 consecutive patients were approached. Of those eligible, 50 were randomized to Prec and 50 to Pvag; 23 women declined randomization because of preference for a vaginal line. Overall, 81 line events occurred in 29 women with a vaginal line and 117 occurred in 34 women with a rectal line. No difference was found in patient acceptability nor in trace quality for the two routes. Despite catheter repositioning and flushing, only 13% of traces showed optimum trace quality throughout the entire investigation; the cough signal quality was worse after provocation, during voiding, and in women with prolapse. CONCLUSIONS: A significant proportion of patients undergoing cystometry expressed a preference for the vaginal line. The quality of output from cystometry was limited by the conditions of the investigation rather than the method of intra-abdominal pressure measurement.

Congenital vesicovaginal fistula in association with hypoplastic kidney and uterus didelphys.

Abnormalities of the lower urinary and genital tracts commonly coexist, although congenital vesicovaginal fistula is extremely rare. We report the first case of congenital vesicovaginal fistula and hypoplastic kidney in association with uterine didelphys. Despite extensive investigation throughout childhood, a definitive diagnosis was not made until 16 years of age. We discuss some of the difficulties that might arise in diagnosing a small vesicovaginal fistula in the presence of a fusion abnormality of the genital tract and suggest how such cases might be investigated and managed surgically.

Opening detrusor pressure and the influence of age on success following colposuspension.

OBJECTIVE: Women with urodynamic stress incontinence (USI) have lower opening and closing detrusor pressures than women without USI. This study was undertaken to determine whether a change occurs in opening and closing detrusor pressures after colposuspension, whether cure is associated with change, and whether age influences cure. DESIGN: Retrospective cohort study. SETTING: Tertiary referral urogynaecology department. PARTICIPANTS: Consecutive women who had undergone colposuspension between 1998-2000 and 1993-1995. METHODS: Pre- and post-operative urodynamic records were reviewed. Eighty eight women were included. Objective cure was defined as an absence of USI and subjective cure as an absence of symptoms of stress incontinence. RESULTS: Mean age was 52.4 (11.0) years. Sixty nine percent (61/88) were objectively cured and 48% (42/88) were subjectively cured. Postoperatively, opening detrusor pressure increased (P = 0.0001) and maximum flow rate decreased (P= 0.0464) in women objectively cured but these parameters did not change in the not cured group (P > 0.05). Women had a 4.5 times higher chance of failed surgery if post-op opening detrusor pressure was < or =20 cmH2O (P = 0.035). Opening detrusor pressure declined with age (P < 0.001) and women who were objectively cured were on average almost 7 years younger (P = 0.0330). CONCLUSIONS: Increase in opening detrusor pressure occurs only in women who are cured following colposuspension. Change in opening detrusor pressure is dependent on age and objective cure is higher in younger women. The effects of ageing on sub-urethral supports might explain why surgery is more likely to fail in older women.

A study of quality of life in primigravidae with urinary incontinence.

This study aimed to establish the prevalence and effect of urinary incontinence on quality of life during pregnancy and after parturition. A prospective cohort of primigravidae was recruited. The Kings Health Questionnaire (KHQ) was self-administered antenatally (34 weeks to term) and postnatally (3 months after delivery). Four hundred ninety-two primigravidae were recruited. The prevalence of urinary incontinence was reported as: pre-pregnancy 3.5% (17/492), antenatal 35.6% (175/492), 3-5 days postpartum 13.7% (51/370) and 3 months postnatal 13.0% (47/362). Most women with urinary incontinence experienced an impact on quality of life antenatally (54.3%) and postnatally (71.1%), although those experiencing an impact usually reported it as 'a little' (75.8 and 87.5%). There was a higher prevalence of urinary incontinence after forceps delivery ( p<0.05) but not of greater impairment in quality of life ( p>0.05). Personal and general health deteriorated postnatally ( p<0.05). During pregnancy most women with urinary incontinence experience minimal impact on quality of life. Postnatally, other causes of morbidity may contribute to worsening of general and personal health.

Stress incontinence and pelvic floor neurophysiology 15 years after the first delivery.

UNLABELLED: HEADLINE: This is a longitudinal study of a cohort of primigravidae recruited between 1985 and 1987 and followed up 7 and 15 years later. Pelvic floor neurophysiology was performed and questionnaires were administered to determine the natural history of stress incontinence and to establish whether pelvic floor denervation after the first delivery is associated with symptoms of stress urinary incontinence in the future. OBJECTIVES: To study the natural history of stress urinary incontinence arising during the first pregnancy, to determine whether postnatal pelvic floor denervation progresses with time and whether it predisposes to stress urinary incontinence in the future. DESIGN: Prospective longitudinal cohort study. SETTING: Tertiary referral urogynaecology unit. SAMPLE: Cohort of 96 primigravidae studied prospectively between 1985 and 1987 and followed up 7 years (n = 76) and 15 years (n = 55) later. METHODS: Urinary incontinence symptoms were recorded and pelvic floor neurophysiology was performed antenatally and postnatally between 1985 and 1987. Repeat neurophysiological tests and questionnaires were completed by those relocated 7 and 15 years later. MAIN OUTCOME MEASURE: Symptoms of stress urinary incontinence. SECONDARY OUTCOMES: Symptoms of urge urinary incontinence and anal incontinence; motor unit potential duration and pudendal nerve terminal latency; vaginal squeeze pressure measured by perineometry. RESULTS: Prevalence of stress incontinence was highest during pregnancy and had increased seven years after the first postnatal period (P = 0.0129). Two-thirds of women with antenatal stress incontinence had stress incontinence 15 years later. One-third of women with stress incontinence at any time appear to undergo resolution of symptoms. Motor unit potential duration increased at seven years (P = 0.036). Vaginal squeeze pressure improved during the same period (P = 0.0007). CONCLUSIONS: When stress urinary incontinence arises during the first pregnancy, the risk of stress incontinence occurring 15 years later is doubled. Although pelvic floor reinnervation progressed after the postnatal period, the absence of an adequate marker for pelvic floor denervation makes it of uncertain clinical significance.