Erbium:YAG laser treatment of female stress urinary incontinence: midterm data.

INTRODUCTION AND HYPOTHESIS: Stress urinary incontinence (SUI) is treated using intravaginal laser therapy. We wanted to find out how incontinence severity at baseline and the number of laser interventions affect success rate, and whether the effect of laser therapy was obvious 6 months and 2 years after the last laser intervention. METHODS: Fifty-nine women, 32 with SUI I, 16 with SUI II, and 11 with SUI III were treated using an erbium-doped yttrium aluminium garnet (Er:YAG) laser following the IncontiLase® protocol. Therapy included five laser sessions with a 1-month interval between sessions. Objective (1-h pad test) and subjective data (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form [ICIQ-UI SF], Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire [PISQ-12]) were assessed at baseline, after two and four laser sessions and 6 months and 2 years after the fifth laser session. RESULTS: Objective cure/improve rates for mild SUI I were 69%, 78%, 91%, and 78% after two, four, and five laser sessions at the 6-month and 2-year follow-ups. Subjective cure rates (ICIQ-UI SF) were 53%, 69%, 72%, and 66%, and sexual function (PISQ-12) also improved. For SUI II, objective cure/improve rates were 31%, 63%, 69%, and 50%. Subjective cure rate was 13% at the 2-year follow-up. For SUI III, only one patient had an objective improvement after two and four laser sessions. CONCLUSIONS: Intravaginal laser therapy led to cure/improvement for SUI I and SUI II, but not for severe SUI III. Outcome was better after four to five laser sessions than after two laser sessions. Follow-up data 6 months and 2 years after laser intervention showed sustainability of the treatment.

Demographic features of female urethra length.

AIMS: To determine cohort urethral length, identify epidemiological factors influencing the parameter and to establish the percentage of cases with clinically relevant outsized urethras. METHODS: Prospective cohort study conducted in two tertiary clinical centers between 2013 and 2017. Nine hundred and twenty seven consecutive adult, Caucasian females attending outpatients' clinics were included. The urethral length has been measured in pelvic floor ultrasound examination. The exclusion criteria were inadequate bladder filling (<200 mL; >400 mL), previous history of pelvic floor surgery, and no consent. RESULTS: Urethral length varied from 19 to 45 mm. The distribution of the examined parameter was normal. Obese patients had significantly longer urethras as compared to non-obese subjects. Number of vaginal deliveries was connected with shorter urethral length. The limitations of the study are: analysis only of Caucasian patients and subjects without previous pelvic floor surgeries. CONCLUSIONS: Differences in urethral length in the female population were demonstrated. Thirty percent of patients have atypical urethras that may be a risk factor for sling surgery failure. We therefore postulate introduction of urethral measurement before the procedure.

Urethral funneling visualized during pelvic floor sonography - analysis of occurrence among urogynecological patients.

OBJECTIVES: There are different diagnostic methods used in women with urinary incontinence symptoms such as: medical history, voiding diary, cough test, pad test, urodynamic testing. None of them is optimal. The aim of this study is to analyze the correlation between urethral funneling visualized during pelvic floor sonography and symptoms of stress urinary incontinence. MATERIAL AND METHODS: We have performed a retrospective analysis of 657 complete datasets of patients who attended our urogynecological clinic for diagnostics. Women with wet overactive bladder were excluded from the analysis. Tests used in our clinic included: standardized interview and questionnaire, clinical exam, cough test. Pelvic floor sonography with a transvaginal probe in women with filled bladder was performed to assess the urethral length and the urethral funneling during maximal Valsalva maneuver. RESULTS: In all patients with clinical SUI symptoms and with a positive cough test the urethral funneling length during Valsalva maneuver was > 50% of urethral length (long urethral funneling). In 83.7% of women without SUI the urethral funneling was absent. In the remaining 16.3% funneling was visible but its relative length was less than 50% of urethral length and urine flow was not observed (short urethral funneling). CONCLUSIONS: Long urethral funneling (> 50% of urethral length) seems to be a characteristic sign for SUI in women. The presence of urethral funneling shorter than 50% of urethral length (short urethral funneling) is not a SUI symptom - it is probably a sign of asymptomatic funneling of bladder neck.

Role of intrinsic sphincter deficiency with and without urethral hypomobility on the outcome of tape insertion.

AIMS: Intrinsic sphincter deficiency (ISD) is a known risk factor for therapy failure after tension-free vaginal tape (TVT) insertion. The purpose of this study was to investigate if the severity of ISD alone or other factors such as urethral mobility and tape localization influence outcomes. METHODS: One hundred and nine women with urodynamically determined ISD, a TVT insertion, and a 6-month follow-up visit were included. Urethral length, mobility, and tape localization were evaluated by pelvic floor sonography. Patients were classified into three urethral mobility groups (hypomobile, normomobile, hypermobile). Surgical outcome was assessed by a combination of objective and subjective criteria. RESULTS: Therapeutic success rate after TVT insertion was 81.6%. The severity of ISD did not associate with therapy failure. But urethral mobility (P < 0.0001), relative tape position (P = 0.0003), and tape-urethra distance (P < 0.0001) differed between cured and not cured patient groups. Patients with a relative tape position toward 1/2 of urethral length had a higher cure rate. Significantly different cure rates (P = 0.0003) were found for hypomobile (67%), normomobile (76%), and hypermobile (100%) urethras. For ISD patients with a hypomobile urethra, highest cure rates were obtained for tape-urethra distances between 2.5 and 3.5 mm. CONCLUSIONS: The reduced cure rate for ISD patients was due to the subgroup with a hypomobile urethra. A prospective study is needed to confirm that slightly shorter tape-urethra distances and a relative tape position more toward the mid-urethra will lead to better outcomes for this patient group.

Are complications of stress urinary incontinence surgery procedures associated with the position of the sling?

OBJECTIVES: To evaluate whether the sling position is associated with particular types of complications in patients undergoing suburethral sling placement for stress urinary incontinence. METHODS: Data from 100 women diagnosed at the Evangelical Hospital Hagen-Haspe with complications after suburethral sling insertion were analyzed. All patients underwent pelvic floor ultrasound to assess: urethral length, sling location in relation to the urethral length (%) and the sling distance to the longitudinal smooth muscle complex of the urethra (the sling-longitudinal smooth muscle distance). RESULTS: The shortest median sling-longitudinal smooth muscle distance was observed in patients with recurrent urinary tract infections, urinary retention and overactive bladder: 0.9, 1.1 and 1.75 mm, respectively (P < 0.05). In women with persistent stress urinary incontinence and sling erosion, the sling-longitudinal smooth muscle distance was 3.6 and 4.6 mm, respectively (P < 0.05). Persistent stress urinary incontinence was connected with the position of the sling in relation to the bladder neck - in these patients, the sling was closer to the bladder neck. CONCLUSIONS: Sling location plays a pivotal role in the occurrence of certain complications. The sling position in the proximal part of the urethra or between the middle and proximal urethra appears to be connected with a high rate of unsuccessful stress urinary incontinence treatment. A sling-longitudinal smooth muscle distance below 2 mm is often connected with sling complications, such as overactive bladder, urinary retention and recurrent urinary tract infections.

Does the suburethral sling change its location?

OBJECTIVES: To ascertain whether a phenomenon of sling migration exists after suburethral sling placement, whether this might be responsible for suboptimal sling location and persistent incontinence, and whether a link exists between sling dislocation or migration and risk factors, such as obesity or age. METHODS: The present prospective cohort study was carried out in a group of 244 patients who underwent retropubic sling implantation. Sling location was determined by means of pelvic floor ultrasound, and calculated relative to the individual patient's urethral length measured before the procedure. The sling location was visualized on 1 day, and 1 and 6 months post-surgery. Overweight/obese and elderly patients were analyzed separately to assess the possible influence of those factors on sling location. RESULTS: The mean urethral length in the studied cohort was 28.76 ± 3.67 mm. The mean tape position 1 day post-surgery was 66.18 ± 8.43% of the urethral length, and it did not change 1 and 6 months post-surgery in the whole group. Similar results were obtained in elderly and overweight/obese patients. CONCLUSIONS: Suboptimal sling location appears to result from incorrect surgical technique, and should be diagnosed and treated early after the primary surgery. Sling location does not change after mid-term follow up.

The analysis of repeatability and reproducibility of bladder neck mobility measurements obtained during pelvic floor sonography performed introitally with 2D transvaginal probe.

OBJECTIVES: The aim of the study was the evaluation of repeatability and reproducibility of chosen urethral neck mobility measurements obtained during introital pelvic floor sonography performed with a 2D transvaginal probe. MATERIAL AND METHODS: In order to assess the repeatability and reproducibility, independent measurements on the ultra-sound image were taken by two specialists on 92 female patients at rest and at strain (Valsalva maneuver). 2D ultrasound examination was performed introitally with a transvaginal probe (PFS-TV). The location of the urethral internal orifice was defined with coordinates of two points. Point CI marks the urethral anterior edge visualized on ultrasound as closer to the pubic symphysis. Point CII marks the posterior edge visualized more peripherally from pubic symphysis. RESULTS: Repeatability and reproducibility measurements of point CI location and mobility were good and very good (0.6710-0.9961), while of point CII - were medium, good and very good (0.5738-0.9944). Point CI was clearly visible in all cases. It was not possible to accurately mark point CII in 4.3-17.4% of cases. CONCLUSIONS: The possibility to visualize point CI in every single case with very good and good repeatability and reproduc-ibility of measurements of this point's location and mobility allows the usage of CI point as a universal reference point for evaluation of bladder neck mobility and position during PFS-TV in the clinical practice and for research purposes.

Do different vaginal tapes need different suburethral incisions? The one-half rule.

AIM: Despite a wide array of vaginal tapes to treat stress urinary incontinence (SUI), evidence suggesting that both patient characteristics and tape positioning influence outcomes, and differing tape insertion pathways (retropubic vs. transobturator), it remains unclear if the same incision location is effective for all tapes. The aim of the study was to compare outcomes using two different surgical incision locations when inserting a transobturator vaginal tape (TOT) to treat SUI. METHODS: We compared patient characteristics, tape positioning, and surgical outcomes in 123 women undergoing a TOT procedure who were randomly assigned to have the surgical incision begin at 1/3 of the sonographically-measured urethral length (similar to the traditional retropubic approach) or 1/2 of the urethral length. RESULTS: It was feasible to place the tape according to intention in 99.2% of the study cohort. The overall cure rate was higher when the incision site began at 1/2 the urethral length (83.6%) than 1/3 (62.9%) (P = 0.01). In the subgroup analyses, only patients with normal urethral mobility had significantly different cure rates (85.7% vs. 55.2%, P = 0.02). No significant differences in cure rates were observed between the other mobility categories of the study groups-hypermobility was consistently associated with high cure rates and hypomobility with low cure rates. CONCLUSIONS: When surgically treating SUI with a TOT, incision at the mid-urethra using the 1/2 rule is recommended as it leads to better outcomes for most patients, particularly those with normal urethral mobility.

Ultrasound and early tape mobilization--a practical solution for treating postoperative voiding dysfunction.

AIMS: This study assessed the effectiveness of ultrasound in determining tape distance to urethra and the impact of early tape mobilization on outcomes in women with postoperative voiding dysfunction resulting from a too tightly positioned tension-free vaginal tape (TVT). METHODS: A prospective observational study was conducted with women experiencing voiding dysfunction caused by too tightly positioned tapes. Ultrasound was used to identify the cause of the dysfunction and measure the distance between tape and longitudinal smooth muscle layer (LSM) of the urethra. If the tape was too close to the LSM (<3 mm) and the residual volume was >100 ml, it was mobilized under local/analgosedation shortly after the initial TVT procedure. RESULTS: Seventy-one postoperative TVT mobilization procedures were conducted on 61 women, which was 4.1% (61/1501) of all suburethral tape procedures performed. Early tape mobilization restored normal micturition in 59 (96.7%) of the women at the time of discharge. Significant differences were found in residual volumes (P < 0.001) and tape-LSM distances (P < 0.001) pre- and post-mobilization. At 6-month follow-up visits, 58 (95.1%) women were cured of SUI, three were incontinent, and no additional voiding dysfunction occurred. CONCLUSIONS: Immediate postoperative ultrasound can reliably detect too tightly positioned tapes that can be promptly treated with tape mobilization, a short and safe procedure that does not compromise the outcome of the original procedure.

Bladder perforation after TVT-Secur procedure: how secure is TVT-Secur?

BACKGROUND: A rare but challenging complication of midurethral tape procedures is perforation of the tape through the bladder wall. CASES: We saw three patients in whom unrecognized bladder perforation during TVT-Secur procedures occurred. It took an average follow-up time of 11 months before the bladder perforations were identified by introital ultrasound. Complete excision of the mesh was achieved endoscopically (TURP resectoscope) and/or by traditional vaginal tape removal techniques. Following tape removal, there has been no recurrence of urinary tract infections, and the irritative voiding symptoms have resolved in all three cases. CONCLUSIONS: Bladder perforation after mini-sling procedures can be managed using a combined transurethral/vaginal approach. This technique is minimally invasive, safe, and successful. Careful introital ultrasound should be performed in patients presenting with new lower urinary tract symptoms after sling surgery to avoid delays in diagnosing bladder perforation.

Complications of sub-urethral sling procedures.

Approximately one-third of the female population has been estimated to suffer from stress urinary incontinence. Surgical management of this disorder has been an area of ongoing innovation since the beginning of the 20th century. Better understanding of the underlying patomechanisms resulted in the invention of suburethral sling, that proved to be very effective in terms of the cure rates. The introduction of sling techniques also caused a considerable reduction of the rates of intra- and postoperative complications of incontinence treatment. Unfortunately modern anti-incontinence surgery continues to be associated with a high risk of both, perioperative morbidity and long-term adverse outcomes, even with the recently introduced single-incision techniques. The article focuses on intra- and postoperative complications of sling techniques in anti-incontinence surgery. Both, common and rare adverse outcomes are widely discussed.

Current Treatment of Stress Urinary Incontinence by Bulking Agents and Laser Therapy-An Update.

Stress urinary incontinence (SUI) affects around 20% of women. In addition to the established suburethral sling insertion, two less invasive approaches are of interest today: urethral bulking agents and vaginal laser therapy. This review discusses articles through December 2023 identified by a PubMed literature search using the keywords "incontinence" and "bulking" or "laser". Although the two approaches are less effective than sling insertions, there are specific conditions in which one or the other technique is more advantageous. Injecting bulking agents into the urethra only takes some minutes and works without general anesthesia. The method is particularly suited for elderly, frail, or obese patients with multiple comorbidities, but is also applicable for all patients and in combination with other therapies. Generally, the safety profile is good but differs between bulking materials. Two laser types-the Erbium:YAG laser with SMOOTH-mode and the fractional ablative CO2 laser-deliver heat into the tissue to induce tissue tightening and regeneration. Intravaginal laser therapy improves mild to moderate SUI, while studies describe how intraurethral laser therapy is also beneficial for severe SUI. Young women between childbirths, as well as postmenopausal women, may benefit from laser therapy. The method is safe, can be performed on an outpatient basis, and does not require any artificial material.

Midurethral sling incision: indications and outcomes.

INTRODUCTION AND HYPOTHESIS: Controversy continues over the effectiveness of sling incision, which is the most common operative approach to treating complications following suburethral sling insertion. This retrospective analysis assessed the indications for sling incision and patient outcomes regarding resolution of complications and stress urinary incontinence. METHODS: A review was conducted of the medical records of women who underwent sling incision between 2003 and 2010. Data such as surgical indications, ultrasound findings and medical outcomes were extracted from 198 records, and descriptive and inferential statistical methods of analysis were used. RESULTS: In the 198 patients eligible for study inclusion, the primary reasons for sling incision were overactive bladder (68 %), voiding dysfunction (61 %), and recurrent urinary tract infections (53 %). Additional complications included dyspareunia (18 %), chronic pelvic pain (17 %), and sling exposure (15 %). Sling incision led to immediate postoperative cure of voiding dysfunction in 97 % of patients. Cure rates for overactive bladder and dyspareunia were 60 % and 94 % respectively. Chronic pelvic pain was resolved in 82 % of cases and all cases of sling exposure were cured. Eighty-five (61 %) of the 140 patients who were continent before sling incision developed recurrent stress urinary incontinence (SUI) postoperatively. CONCLUSIONS: These findings indicate that sling incision can be highly successful in improving voiding dysfunction and dyspareunia, and moderately successful in curing overactive bladder and chronic pain. However, SUI may recur in more than 60 % of the patients undergoing sling incision. Consequently, patients being considered for a sling incision procedure should be informed about this possible complication.

Introital ultrasound in the diagnosis of occult abscesses following a tape procedure: a case report.

We report a case of a 59-year-old woman who suffered for 3 years with vaginal discharge and severe lower abdominal pain. The patient underwent numerous clinical examinations and a wide array of complex medical procedures without receiving a conclusive diagnosis. Although a diverse amount of tests and exams had been carried out, no abnormalities were detected until introital ultrasound (GE Voluson 730 Expert, vaginal probe 5-9-MHz, beam angle of 160°) identified two tiny abscesses with sinus tract at the vaginal sulci. The infected tape (TOT) was surgically removed and the patient healed uneventfully.

Diagnosis and Therapy of Female Urinary Incontinence. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry No. 015/091, January 2022): Part 2 with Recommendations on Interventional/Surgical Therapy of Overactive Bladder, Surgical Treatment of Stress Urinary Incontinence and Diagnosis and Therapy of Iatrogenic Urogenital Fistula.

Aim This completely revised interdisciplinary S2k-guideline on the diagnosis, therapy, and follow-up care of female patients with urinary incontinence (AWMF registry number: 015-091) was published in December 2021. This guideline combines and summarizes earlier guidelines such as "Female stress urinary incontinence," "Female urge incontinence" and "Use of Ultrasonography in Urogynecological Diagnostics" for the first time. The guideline was coordinated by the German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and the Working Group for Urogynecology and Plastic Pelvic Floor Reconstruction (Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V., AGUB). Methods This S2k-guideline was developed using a structured consensus process involving representative members from different medical specialties and was commissioned by the Guidelines Commission of the DGGG, OEGGG and SGGG. The guideline is based on the current version of the guideline "Urinary Incontinence in Adults" published by the European Association of Urology (EAU). Country-specific items associated with the respective healthcare systems in Germany, Austria and Switzerland were also incorporated. Recommendations The short version of this guideline consists of recommendations and statements on the surgical treatment of female patients with stress urinary incontinence and urge incontinence. Specific solutions for the diagnostic workup and treatment of uncomplicated and complicated urinary incontinence are discussed. The diagnostics and surgical treatment of iatrogenic urogenital fistula are presented.

Diagnosis and Therapy of Female Urinary Incontinence. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/091, January 2022): Part 1 with Recommendations on Diagnostics and Conservative and Medical Treatment.

Aim This completely revised interdisciplinary S2k-guideline on the diagnosis, therapy, and follow-up care of female patients with urinary incontinence (AWMF registry number: 015-091) was published in December 2021. This guideline combines and summarizes earlier guidelines such as "Female stress urinary incontinence," "Female urge incontinence" and "Use of Ultrasonography in Urogynecological Diagnostics" for the first time. The guideline was coordinated by the German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and the Working Group for Urogynecology and Plastic Pelvic Floor Reconstruction (Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V., AGUB). Methods This S2k-guideline was developed using a structured consensus process involving representative members from different medical specialties and was commissioned by the Guidelines Commission of the DGGG, OEGGG and SGGG. The guideline is based on the current version of the guideline "Urinary Incontinence in Adults" published by the European Association of Urology (EAU). Country-specific items associated with the respective healthcare systems in Germany, Austria and Switzerland were also incorporated. Recommendations The short version of this guideline consists of recommendations and statements on the epidemiology, etiology, classification, symptoms, diagnostics, and treatment of female patients with urinary incontinence. Specific solutions for the diagnostic workup and appropriate conservative and medical therapies for uncomplicated and complication urinary incontinence are discussed.

Functional Polymorphism in the ADRB3 Gene, Encoding the Beta-3 Adrenergic Receptor, and Response to Intra-Detrusor Injection of Botulinum Toxin-A in Women with Overactive Bladder.

BACKGROUND: There are reports suggesting an association between the rs4994 polymorphism in the ADRB3 gene encoding the beta-3 adrenergic receptor and OAB risk in females. The injection of botulinum toxin-A into the bladder wall is recommended as a possible treatment for OAB patients in whom first-line therapies have failed. The aim of our study was to analyze the possible association between the ADRB3:rs4994 polymorphism and the patient-perceived response to a single intra-detrusor injection of botulinum toxin-A in Polish women with overactive bladder. METHODS: The study group consisted of 115 consecutive female patients with OAB. The response to botulinum toxin-A was evaluated at three months after injection, as absolute or relative reductions in OAB symptoms or in scores from questionnaires ICIQ-OAB (parts A and B) and ICIQ-LUTS-QoL (parts A and B). ADRB3:rs4994 variants were identified by the sequencing of genomic DNA extracted from buccal swabs. RESULTS: There were no statistically significant differences between ADRB3:rs4994 [T];[T] homozygotes and [T];[C]+[C];[C] subjects for absolute or relative reductions in symptoms or in scores from all four questionnaire parts at three months after the injection of botulinum toxin-A. CONCLUSIONS: Our results do not support the hypothesis that ADRB3:rs4994 polymorphism is associated with the response to the intra-detrusor injection of botulinum toxin-A in Polish females with overactive bladder.

Atrial fibrillation during pregnancy: a 9-month period with limited options.

Pregnancy is a physiological condition with reversible hemodynamic, neurohormonal and coagulation changes to the maternal body during this 9­month period. The occurrence of atrial fibrillation (AF) is altogether rare among pregnant women, but necessitates immediate treatment und further work-up. Despite numerous pharmacological and invasive therapeutic modalities for AF in non-pregnant patients, very few options are considered safe enough for the fetus and the mother during pregnancy. Commonly used medications such as beta blockers, calcium channel antagonists, antiarrhythmic drugs and anticoagulation therapy must be carefully individualized according to the week of gestation and possible underlying comorbidities of the mother, thus highlighting the importance of an interdisciplinary evaluation by a cardiologist and a gynecologist. The current review summarizes the existing knowledge and treatment options for AF in pregnancy and suggests a simplified algorithm for this clinical constellation.

How to balance the treatment of stress urinary incontinence among female athletes?

Urinary incontinence in the general population occurs in 7% of non-pregnant women under 39 years old, 17% of those 40 to 59 years old, and 23-32% of those over 60 years old. In athletes the prevalence is higher, especially in high-impact training and gravity sports. Pelvic floor muscles (PFM) have two important roles; they serve as the support for abdominal organs and are crucial for closure of the urethra, vagina and rectum. We present the proper mechanisms of PFM caudal contractions with proper abdominal muscle control to avoid excessive intra-abdominal pressure. Pelvic floor sonography is discussed as the only objective method for pelvic floor examination among sportswomen and a tool which should be used routinely by urophysiotherapists and urogynecologists. A multidisciplinary individualized approach to stress urinary incontinence among athletes is presented including: physiotherapy, diagnostic imaging, use of a pessary, tampons, pharmacologic and surgical treatment. We present guidelines for stress urinary incontinence treatment in sportswomen of different age.

Tape functionality: position, change in shape, and outcome after TVT procedure--mid-term results.

INTRODUCTION AND HYPOTHESIS: This study evaluates the relevance of the tape position and change in shape (tape functionality) under in vivo conditions for mid-term outcome. METHODS: Changes in the sonographic tension-free vaginal tape (TVT) position relative to the percentage urethral length and the tape-urethra distance were determined after 6 and 48 months in 41 women with stress urinary incontinence. RESULTS: At 48 months, 76% (31/41) of women were cured, 17% (7/41) were improved, and 7% (3/41) were failures. Disturbed bladder voiding was present in 12% (5/41), de novo urge incontinence in 7% (3/41). The median TVT position was at 63% of urethral length. Median tape-urethra distance was 2.7 mm, ranging from 2.9 mm in continent patients without complications to 1.1 mm in those with obstructive complications. Patients with postoperative urine loss had a median distance of 3.9 mm. The tape was stretched at rest and C-shaped during straining in 15 of 41 women (37%) at 48 months (all continent). Patients with this tape functionality at 6 months were also cured at 48 months in 86% of cases (19/22), and only 14% (3/22) showed recurrent incontinence. CONCLUSIONS: Mid-term data suggest an optimal outcome if the tape is positioned at least 2 mm from the urethra at the junction of the middle and distal thirds. Patients with optimal tape functionality at 6 months are likely to show mid-term therapeutic success.