Periurethral injection with polyacrylamide after previous TVT surgery.

INTRODUCTION AND HYPOTHESIS: The aim of this registry study was to assess the clinical utility of using periurethral bulking with polyacrylamide hydrogel in women with stress urinary incontinence (SUI) after previous midurethral sling surgery. METHODS: The study period was 2007 through 2019. Using data from the Norwegian Female Incontinence Registry we included 57 women who had received Bulkamid® because of insufficient improvement or recurrent SUI after previous retropubic TVT surgery. The primary outcome was cure of SUI, and secondary outcomes were patient satisfaction, degree of leakage, change in urgency incontinence (UUI), free flow rate, postvoid residual volume, and complications. Descriptive statistics were used to characterize data and Wilcoxon signed-rank test to compare pre- and postoperative results for pairs, with level of significance at p < 0.05. RESULTS: Pure SUI was seen in 19 (33.3%) while 38 (66.7%) had mixed incontinence. Postoperatively 72.9% had a negative stress test and 73.7% were satisfied with treatment. There was only 1 complication in 67 injections (1.5%). De novo UUI occurred in five patients, corresponding to 8.8% of the whole study group, but 26.3% among those with no preoperative UUI problems. Among the patients with preoperative UUI, 39.5% were cured of this problem and a further 36.8% were improved. CONCLUSIONS: The cure rate and satisfaction rate of periurethral bulking with polyacrylamide after previous MUS are favorable and complications are rare. There seems to be a risk of overactive bladder symptoms developing in women with no such symptoms preoperatively.

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.

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.

A Nordic registry-based study of drug treatment patterns in overactive bladder patients.

Aim: To describe treatment patterns in Denmark, Norway and Sweden for patients receiving overactive bladder (OAB) pharmacotherapy.Methods: This was a prospective, multinational, registry-based study involving three nationwide prescribed drug registries (sample size 6000 patients per country), performed between 1 January and 30 June 2014. Patients were followed prospectively for 12 months after first pick-up of index medication. The primary objective was to evaluate the proportion of patients picking up first refill of index medication. Secondary objectives included evaluation of the average number of pick-ups collected during 1 year and time to discontinuation of index medication.Results: A high proportion of patients in the three Nordic countries picked up a first refill of OAB medication: 64-75% for mirabegron and 84-95% for individual antimuscarinics. Amongst treatment-naïve patients, the proportion picking up their first mirabegron refill was 60-64%; for individual antimuscarinics it was 30-63%. Mean number of pick-ups during 1 year ranged from 3.5-5.0 for mirabegron across the countries and for individual antimuscarinics from 3.8-12.3. Median time to discontinuation for mirabegron ranged from 140 (Denmark) to 207 days (Norway) and, for individual antimuscarinics (solifenacin), from 182 (Denmark) to 355 days (Sweden). At 12 months, the proportion of patients still on treatment with mirabegron and antimuscarinics was 21% and 38%, respectively.Conclusions: Treatment patterns in patients with OAB picking up a mirabegron or antimuscarinic prescription in Denmark, Norway and Sweden indicate that persistence remains a challenge.

Periurethral injection therapy in women with stress incontinence. / Periurethral injeksjonsbehandling hos kvinner med stressinkontinens.

Periurethral injection offers an alternative to the current main method for surgical treatment of stress incontinence in women, which is a polypropylene sling that is placed without tension below the mid-urethra. Injection therapy is a simple, gentle method that provides significant improvement in the degree of leakage and quality of life, but the results are not on a par with the polypropylene sling. Injection therapy may be relevant when the main method is not suitable or desired.

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.

Outcome of TVT operations in women with low maximum urethral closure pressure.

AIMS: (i) To establish whether low maximal urethral closure pressure (MUCP) is associated with a poorer prognosis after TVT-surgery, and if so to establish an MUCP cut-off value for poor outcome. (ii) To characterize the population with a low MUCP. METHODS: Retrospective analysis of data from 6,646 women with stress/mixed urinary incontinence included in the Norwegian Female Incontinence Registry. Postoperative subjective (degree of satisfaction), objective (leakage on stress test) and composite cure according to preoperative MUCP were analyzed in unadjusted and adjusted analysis. Preoperative variables were compared between women having a low or normal MUCP. Non-parametric tests were used on continuous variables and χ2 tests on categorical variables. Logistic regression was used for the adjusted analysis. Level of significance: P < 0.05. RESULTS: An analysis of centiles of preoperative MUCP showed that a cut-off at 20 cm H2 O did best identify women at risk of not being cured. In unadjusted analysis MUCP ≤20 cm H2 O (n = 422) was associated with objective (OR: 2.48), subjective (OR: 1.60), and composite failure (OR: 1.95) compared to MUCP >20 cm H2 O. In adjusted analysis MUCP ≤20 cm H2 O was associated with neither objective, subjective, nor composite failure. Women with MUCP <20 cm H2 O were preoperatively significantly older, had larger leakage on stress and 24 h pad test, lower mean voided volume and maximum flow rate and higher stress and urge indices. CONCLUSIONS: Women with MUCP ≤20 cm H2 O have similar objective, subjective, and composite outcomes after TVT-surgery compared to women with MUCP >20 cm H2 O after adjusting for preoperative variables. Neurourol. Urodynam. 36:1320-1324, 2017. © 2016 Wiley Periodicals, Inc.

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.

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.

Pad stress tests with increasing load for the diagnosis of stress urinary incontinence.

AIM: The aim of the study was to test the ability of pad stress tests with increasing load (supine, jumping on the floor, and jumping on a trampoline) to document stress incontinence in subjectively stress incontinent women. METHODS: In this prospective study 147 subjectively stress and mixed incontinent women performed consecutively the three pad stress tests with a bladder volume of 300 ml. Nineteen women performed a second trampoline pad stress test to test repeatability of the test. Nine continent women performed a trampoline pad stress test in order to determine if subjectively continent women would leak during the test. RESULTS: Seventy-two women (49%) leaked during the supine, 136 (93%) leaked during the jumping, and 146 (99%) leaked during the trampoline pad stress test. The differences between pad stress tests were significant with P < 0.005. Correlation between the two trampoline pad stress tests was high at 0.8. None of the nine continent women leaked during the trampoline pad stress test. CONCLUSION: The supine pad stress test has low sensitivity and is therefore often falsely negative. The jumping pad stress test is a simple test to perform and is satisfactory for everyday use. Subjectively stress incontinent women who do not leak during the jumping pad stress test may perform a trampoline pad stress test to document stress incontinence. The trampoline pad stress test is also simple to perform and detected leakage in 91% of the women who did not leak during the jumping pad stress test.

How often does detrusor overactivity cause urinary leakage during a stress test in women with mixed urinary incontinence?

INTRODUCTION AND HYPOTHESIS: The study examined how often detrusor overactivity (DO) causes leakage during a stress test in women with mixed urinary incontinence (MUI) and whether there are differences between those who do and those who do not have DO during the stress test. METHODS: A retrospective study was performed in 100 women who had an ambulatory urodynamic recording done where bladder, urethral, and vaginal pressures, and leakage were recorded. The stress test consisted of 20 jumping jacks and three forceful coughs. RESULTS: All the women leaked during the stress test: five due to simultaneous stress test and DO, 87 due to the stress test only, and eight during the stress test as well as due to DO before or after the stress test. CONCLUSIONS: During the stress test, 5 % of women with MUI leaked due to the coughs and jumps and simultaneous DO. Women in whom DO was detected had significantly higher Urgency Incontinence Index and leakage during the 24-h pad test.

Long-term follow-up of the retropubic tension-free vaginal tape procedure.

INTRODUCTION AND HYPOTHESIS: Retropubic tension-free vaginal tape (TVT) was introduced in 1996 as a new and innovative surgical approach in the treatment of stress urinary incontinence (SUI). In this study we evaluate the long-term objective and subjective outcomes in a non-selected patient population 10 years after the retropubic TVT procedure. METHODS: All women (603) operated on with retropubic TVT at four gynecological departments from September 1998 through December 2000 were identified, and those still alive (542) were invited to participate in this population-based prospective study. For subjective data a short-form urinary incontinence disease-specific questionnaire was used. For objective evaluation the women underwent a stress test. Data collected were merged with previously stored data in the Norwegian National Incontinence Registry Database. RESULTS: We included 483 women; 327 attended a clinical follow-up consultation and 156 had a telephone interview. Median duration of follow-up was 129 months. Objective cure rate was 89.9 %, subjective cure rate was 76.1 %, and 82.6 % of the patients stated they were "very satisfied" with their surgery (treatment satisfaction rate). Only 2.3 % of the women had undergone repeat SUI surgery. Subjective voiding difficulties were reported by 22.8 %, the majority describing slow stream or intermittency. De novo urgency incontinence increased significantly from 4.1 % 6-12 months after surgery to 14.9 % at the 10-year follow-up. CONCLUSIONS: Long-term objective and subjective outcome after retropubic TVT is excellent with a low number of re-operations even in a non-selected cohort of patients.

Ten-year follow-up after conservative treatment of stress urinary incontinence.

A follow-up study was done in 33 women 10 years after they had participated in a study on conservative treatment of stress urinary incontinence. The evaluation included a 24-h pad test, a short stress test, and two validated quality of life questionnaires. Currently, five women (15%) were still doing pelvic floor muscle training at least twice per week. During the interim, 15 (47%) women had undergone stress incontinence surgery, and 12 (80%) of these were continent. Among the 18 non-operated women, only one (6%) was continent. The difference is statistically highly significant (p < 0.0001). In conclusion, 10 years after conservative treatment of stress incontinence, 85% of the women had stopped conservative treatment, and 94% of those not operated were still incontinent. Significantly more of those who had undergone interval incontinence surgery were now continent.

Follow-up of TVT operations in 1,113 women with mixed urinary incontinence at 7 and 38 months.

A follow-up was done 7 and 38 months after tension-free vaginal tape (TVT) operation in 1,113 women with mixed urinary incontinence. Mixed incontinence and predominant bother were subjectively defined. The results were analyzed according to the women's predominant bother: stress incontinence, urge incontinence, or stress and urge incontinence equally. Across the groups, stress incontinence was cured in 87 and 83% of the women at 7 and 38 months, respectively, with no difference between the three groups. Women with predominant stress incontinence had significantly better results at both 7 and 38 months than those in the other groups, especially those predominantly bothered by urge incontinence. Women with mixed incontinence were significantly more often cured both objectively and subjectively at 7 than 38 months. Only 11% of the women experienced an increase in urge incontinence 38 months after TVT. Before a TVT operation, women with mixed urinary incontinence should be informed that their prognosis depends on their predominant bother. TVT is an appropriate treatment in mixed urinary incontinence, but women with predominant urge incontinence have poorer results than those with predominant stress incontinence.

[Stress urinary incontinence in women--current treatment alternatives]. / Stressinkontinens hos kvinner--aktuell behandling.

BACKGROUND: Stress urinary incontinence in women occurs frequently. This paper gives a review of current treatment alternatives. MATERIAL AND METHODS: The paper is based on the report from the 3 rd International Consultation on Incontinence, the Cochrane database, a PubMed search, and my own clinical experience as a urogynaecologist. RESULTS: General practitioners may initiate conservative treatment without extensive evaluation. The first line treatment is pelvic floor muscle exercises (8-12 strong contractions X 3 every other day). Motivation and compliance are extremely important. Electrostimulation and treatment with vaginal cones are other options with comparable efficacy. Weight reduction (5-10%) may improve the condition significantly. Medical treatment with duloxetine tablets has recently become available. The efficacy of duloxetine is similar to that for pelvic floor exercise. Currently the most commonly used surgical procedures are midurethral retropubic or transobturatoric tension free vaginal tape, which are often done as day surgery and have lower morbidity than older procedures. Approximately 90% of the patients are satisfied with the results, and they continue to be so over time. Stress incontinence surgery is associated with complications such as de novo urge incontinence, impaired bladder emptying, recurrent urinary tract infections, pain and genital prolapse, but the risk is probably lower with tension free vaginal tape than with the older surgical methods. INTERPRETATION: Conservative treatment may reduce incontinence in many patients; it is simple, inexpensive and without risk of complications and is therefore the primary treatment option. Surgical treatment may cure the incontinence permanently, but there is a risk of permanent complications.

Patient-perceived discomfort with two coated urinary catheters.

Intermittent catheterization is now the preferred method for urethral catheterization of the urinary bladder when an indwelling catheter is not required. Nevertheless, the procedure may cause discomfort or pain. This randomized, prospective study was done to compare patient-perceived discomfort between two commonly used hydrophilic, single-use catheters in women. A total of 196 women referred to the urogynaecology section in the outpatient department were randomized to be catheterized with either a LoFric (n=102) or a SpeediCath (n=94) catheter. Both catheters are hydrophilic, low friction, single-use, disposable catheters. Discomfort was measured using a visual analogue scale (VAS). The results showed no difference in degree of patient-perceived discomfort between the two groups. Median score was 0.75 VAS points in both groups, which indicates little discomfort. Half of all the patients stated that they experienced no discomfort at all.