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.

1-year outcome after treatment of uterovaginal prolapse with a 6-point fixation mesh.

INTRODUCTION: The aim of this study was to describe the safety and anatomical results of a surgical approach with a single-incision 6-point fixation vaginal mesh for the treatment of pelvic organ prolapse at perioperatively and at 1-year follow-up. MATERIALS AND METHODS: This was a prospective observational study of patients who underwent operation receiving an InGYNious anterior transvaginal mesh. All patients with symptomatic stage II prolapse or higher were included in the study. Exclusion criteria were the unwillingness or inability to give written informed consent, neuromuscular disorders, malignant diseases, previous radiation in the pelvis, or chronic pain syndrome. Every patient completed a structured questionnaire and a full physical examination according to the IUGA-ICS POP-Q staging system before the operation and at 1-year follow-up. RESULTS: Two hundred fifty-four patients (91%) were included in the study. The intraoperative complication rate was 7% with hemorrhage being the most common complication. Six patients (2.4%) had undergone reoperation for prolapse (four out of the six patients had reoperation in the posterior compartment) and were excluded from the objective outcome analysis. In the remaining 248 patients all POP-Q measurements were significantly improved in the anterior and apical compartments. Similarly, urge urinary incontinence and voiding dysfunction improved significantly. CONCLUSIONS: In this series, the objective outcome one year after the InGYNious mesh was good with low numbers of mesh-related problems or reoperation for prolapse.

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.

Interaction of atypical cadherin Fat1 with SoHo adaptor proteins CAP/ponsin and ArgBP2.

Mammalian Fat1 is a giant atypical cadherin/tumor suppressor involved in the regulation of cellular orientation, migration, and growth. Fat1 is implicated in the development of the brain, eye, and kidney. Altered expression or mutations of FAT1 are also associated with cancer and facioscapulohumeral muscular dystrophy (FSHD). Yet, the mechanistic functions of this pathway remain incompletely understood. Here, we report the identification of Sorbin-homology (SoHo) proteins as novel interaction partners of Fat1 by virtue of a yeast-two-hybrid screen. SoHo proteins play diverse roles as adaptor proteins in cell signaling, cell adhesion and sarcomere architecture, including altered expression in cancer and FSHD. Specifically, we found SoHo proteins CAP/ponsin-1 and -2 (Sorbs1) and ArgBP2 (Sorbs2) to interact with the cytoplasmic domain of Fat1. We mapped the interaction to a prolin-rich classic type II PXXP motif within Fat1 and to the three Src-homology (SH3) domains within SoHo proteins using mutant expression in yeast, pulldown assays, and cell culture. Functionally, endogenous ponsin-2 expression of NRK-52E cells at cellular leading edges was lost upon knockdown of Fat1. In summary, our data point to an interaction of Fat1 with SoHo proteins that is able to recruit SoHo proteins to sites of Fat1 expression.

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.

3 Year outcome after treatment of uterovaginal prolapse with a 6-point fixation mesh.

INTRODUCTION: The aim of this study was to describe the intermediate outcome of a single-incision 6-point fixation transvaginal mesh for the treatment of primary and recurrent pelvic organ prolapse (POP). STUDY DESIGN: This was a prospective cohort study including consecutive patients undergoing POP repair with the InGYNious anterior transvaginal mesh. Inclusion criteria were women with symptomatic stage II POP or higher. Exclusion criteria were the unwillingness or inability to give written informed consent, malignant diseases, neuro-muscular disorders, chronic pain syndrome or previous radiation in the pelvis. Every study participant completed a structured questionnaire, a urogynecological examination according to the IUGA-ICS POP-Q staging system and the validated P-QoL questionnaire before the operation and three years postoperatively. RESULTS: 254 patients were included into the study, 179 were available for the three-year follow-up (70 %). Sixteen patients (8.2 %) had undergone reoperation for recurrent or de novo prolapse (12/16 patients underwent reoperation in the posterior compartment) and were excluded from the objective outcome analysis. In the final study group, all POP-Q measurements, urge urinary incontinence and voiding dysfunction were significantly improved. The de novo SUI rate was 27/ 120 (23 %) in women without reoperation for SUI and/ or POP and without primary SUI. No serious adverse events occurred. Four (1.5 %) patients had mesh exposure at the one-year follow-up and been treated with local oestrogen. At three-year follow-up, no new mesh exposure was seen. De novo dyspareunia rate was low (n = 5 (3 %)). CONCLUSIONS: In this study, the objective outcome three years after anterior POP repair with the InGYNious transvaginal mesh was good. The reoperation rate both for mesh related problems or prolapse were rare.

A Randomized Clinical Trial to Evaluate the Effect of Canephron N in Comparison to Ciprofloxacin in the Prevention of Postoperative Lower Urinary Tract Infections after Midurethral Sling Surgery.

Urinary tract infections (UTIs) are one of the most common reasons for antibiotic prescriptions among women worldwide. UTIs are also associated with intra- and postoperative catheterization, which is an essential component of many gynecological surgical procedures, including midurethral sling (MUS) placement. The aim of this study was to compare the incidence of UTI subsequent to a MUS procedure. The study involved 562 female patients who underwent MUS procedures due to stress urinary incontinence (SUI). Patients were assigned in a 1:1 ratio to two study groups: patients receiving 500 mg of ciprofloxacin three times a day for 3 consecutive days after surgery or patients receiving 5 mL of Canephron taken orally three times a day for 3 weeks. After analyzing the collected data, it was found that in the group of patients receiving ciprofloxacin, 29 women (10.98%) had a UTI, whereas in the group of patients receiving Canephron, 36 women (13.64%) had a UTI within 6 months after the patient's MUS procedure. No statistically significant difference between the two groups was noted. Postoperative prophylaxis with a phytodrug can be perceived as an attractive option in the reduction of antibiotic consumption among female patients after a MUS procedure.

Current Treatment Concepts for Stress Urinary Incontinence.

Initially, stress urinary incontinence should be treated by conservative measures, such as weight reduction, hormonal substitution, physiotherapy, pelvic floor exercise and/or the use of pessaries. Incontinence surgeries are only recommended in case of unsuccessful conservative therapy. Today, tension-free suburethral sling insertions represent the gold standard of incontinence surgery yielding very good outcomes (cure rates of 80­90 %). Pelvic-floor sonography provides important information on decision of surgical methods and the management of complications. Furthermore, intra- or paraurethral injection of bulking agents is a promising, minimally invasive surgical alternative. This article discusses treatment concepts, pre-, intra- and post-operative examinations, decision on surgical methods, operational details for surgical success, and the prevention and management of complications.

The Outcome of Repeated Mid Urethral Sling in SUI Treatment after Vaginal Excisions of Primary Failed Sling: Preliminary Study.

Mid urethral sling is the standard in SUI treatment. Nevertheless, the risk of reoperation reaches 9%. There is no consensus as to the best treatment option for complications. A question is raised: what is the optimal way to achieve the best result in patients after primary failure? The aim of the study was to evaluate the outcomes of repeat MUS surgery in patients after excision of the sling with recurrent SUI. We compared its effectiveness with uncomplicated cases treated with TVT. 27 patients who underwent the repeated MUS and 50 consecutive patients after primary TVT were enrolled in the study. After 6 months, we have found that 24 (88.46%) patients from repeat sling group and 48 (96%) patients after primary sling were dry (1-hour pad test, 2 g or less). The difference between groups was not significant. We showed statistically significant improvement of quality of life in both groups. In conclusion, we showed that repeated sling after MUS excision is almost as effective as primary MUS. We postulate that sling excision and repeated MUS may be the best option for persistent SUI and/or complications after MUS procedures. Further multicenter observations are ongoing as to provide results on bigger group of cases.

Vaginal excision of the sub-urethral sling: analysis of indications, safety and outcome.

INTRODUCTION: Sling techniques are the method of choice in stress urinary incontinence management, despite the high rates of complications leading sometimes to the necessity of re-operation, and the tape transection and resection are of the greatest importance. The study was aimed at analyzing the indications, technique and effects of transvaginal tape excision. MATERIAL AND METHODS: A retrospective study including 100 patients who underwent surgical removal of the sub-urethral sling in Evangelisches Krankenhaus Hagen-Haspe was conducted. The analyzed measures were: sling type, onset of symptoms, rates of particular complications, safety and outcome of the operative procedure. RESULTS: Most complications occurred in the first 2 years after surgery. The most common indications for re-operation were: overactive bladder (OAB) (64%), persistent stress urinary incontinence (SUI) (59%), pain (40%), urinary retention (40%), and erosion (29%). Some of the complications co-existed (i.e. vaginal erosion with postoperative pain, infections with urinary retention). During the procedure 1 bladder was injured and 1 patient had a hematoma. In women with OAB, 24-hour frequency decreased from 13.3 to 8.5 (p < 0.001), the mean voiding volume increased from 131.7 to 216.4 ml (p < 0.001), and nocturia increased from 3.28 to 1.19 (p < 0.001). Intensity of urgency decreased from 8.78 to 0.92 in the 10-point visual score (p < 0.001). Pain and urinary retention resolved in 39 out of 40 patients (p < 0.0001). The rate of SUI increased from 59% to 83% (p < 0.001). CONCLUSIONS: Sling removal is safe and associated with a minimal rate of complications. Removing the tape causes resolution of most of the complications, but SUI recurs or worsens.