Risk Factors Affecting Cure After Mid-urethral Tape Procedure for Female Urodynamic Stress Incontinence: Comparison of Retropubic and Transobturator Routes

doi:10.1016/j.urology.2009.01.004

Urology

Volume 73, Issue 5, May 2009, Pages 981-986

https://doi.org/10.1016/j.urology.2009.01.004 Get rights and content

Objectives

To identify the risk factors affecting cure after the tension-free vaginal tape procedure (TVT) or transobturator tape procedure (TOT).

Methods

A total of 121 women with urodynamically proved stress incontinence underwent TVT (n = 61) or TOT (n = 60). We analyzed all data with univariate and multivariate logistic regression analyses.

Results

Univariate analysis revealed that a larger postvoid residual urine volume, greater pad weight test, and lower maximal flow rate were associated with a greater risk of failure to be cured after TVT. A lower maximal urethral closure pressure (MUCP) was associated with a greater risk of failure after the TOT procedure. With additional analysis, we found that a MUCP of ≤40 cm H₂O (odds ratio [OR] 9.21, P = .004) was associated with a significantly greater risk of failure to be cured after the TOT procedure but not a MUCP of ≤50 cm H₂O (OR 2.24, P = .21). Multivariate analysis revealed that preoperative detrusor overactivity was an independent risk factor affecting cure after TVT (OR 113.1, 95% confidence interval 1.84-6592.77, P = .02) or TOT (OR 23.7, 95% confidence interval 1.63-344.53, P = .02), and MUCP ≤40 cm H₂O (OR 8.34, 95% confidence interval 1.52-45.65, P = .01) was another risk factor for TOT.

Conclusions

The risk factors affecting cure after mid-urethral tape procedures were preoperative detrusor overactivity for TVT and TOT and MUCP ≤40 cm H₂O for TOT.

Section snippets

Material and Methods

All female patients with urodynamically proven stress incontinence (USI) who had completed the preoperative urodynamic studies and pad testing and underwent the TVT procedure (using TVT from Ethicon, Somerville, NJ) or the TOT procedure (using Monarc TOT, American Medical Systems, Minnetonka, MN) at National Taiwan University Hospital from January 2004 to February 2007 were studied in a retrospective fashion. All procedures conformed to those described in previous reports1, 2, 12 and were

Results

A total of 61 patients who underwent the TVT procedure and 60 patients who underwent the TOT procedure were included in the present study. All patients (n = 121) were followed up at our hospital for >12 months. Except for the maximal urethral closure pressure (MUCP), operating time, and symptoms of voiding dysfunction (ie, straining to void [n = 5], incomplete emptying [n = 4]), no significant differences were found in the baseline clinical, urodynamic, or perioperative characteristics between

Comment

Using the stress cough test and subjective report of urine leakage, the cure rate in the TVT group was comparable to that of the TOT group (82.0% vs 78.3%, P = .57) despite the lower preoperative MUCP value for the TOT group. The cure rates for both procedures used in this study were within the previously reported ranges.3, 4, 5, 6

In the present study, a MUCP of ≤40 cm H₂O was an independent risk factor for the failure to be cured after the TOT procedure, but not after the TVT procedure.

Conclusions

The presence of preoperative detrusor overactivity was an independent risk factor for the failure to be cured after TVT procedure. The presence of preoperative detrusor overactivity and a MUCP of ≤40 cm H₂O were independent risk factors for the failure to be cured after the TOT procedure.

Acknowledgment

To Chi-ling Chen, Ph.D., Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University for her statistical assistance in this study.

References (30)

A. Fischer et al.
Comparison of retropubic and outside-in transobturator sling systems for the cure of female genuine stress urinary incontinence
Eur Urol
(2005)
E. Darai et al.
Functional results after suburethral sling procedure for urinary stress incontinence: a prospective randomized multicentre study comparing the retropubic and transobturator routes
Eur Urol
(2007)
L.Y. Lin et al.
Sequential assessment of urodynamic findings before and after tension-free vaginal tape (TVT) operation for female genuine stress incontinence
Eur Urol
(2004)
W.Y. Wu et al.
Comparison of 20-minute pad test versus 1-hour pad test in women with stress urinary incontinence
Urology
(2006)
W.Y. Wu et al.
Twenty-minute pad test: comparison of infusion of 250 ml of water with strong-desire amount in the bladder in women with stress urinary incontinence
Eur J Obstet Gynecol Reprod Biol
(2008)
K.S. Lee et al.
A prospective trial comparing tension-free vaginal tape and transobturator vaginal tape inside-out for the surgical treatment of female stress urinary incontinence: 1-year follow up
J Urol
(2007)
K.S. Lee et al.
Outcomes following repeat mid urethral synthetic sling after failure of the initial sling procedure: rediscovery of the tension-free vaginal tape procedure
J Urol
(2007)
J.J. Miller et al.
Is transobturator tape as effective as tension-free vaginal tape in patients with borderline maximum urethral closure pressure?
Am J Obstet Gynecol
(2006)
J.S. Paick et al.
Tension-free vaginal tape procedure for urinary incontinence with low Valsalva leak point pressure
J Urol
(2004)
J.H. Choe et al.
The impact of tension-free vaginal tape on overactive bladder symptoms in women with stress urinary incontinence: significance of detrusor overactivity
J Urol
(2008)

S. Minaglia et al.

Bladder injury during transobturator sling

Urology

(2004)

U. Ulmsten et al.

Intravaginal slingplasty (IVS): An ambulatory surgical procedure for treatment of female urinary incontinence

Scand J Urol Nephrol

(1995)

E. La Delmore

Bandelette transobturatrice: un procédé mini-invasif pour traiter l'incontinence urinaire de la femme

Prog Urol

(2001)

M.D. Barber et al.

Transobturator tape compared with tension-free vaginal tape for the treatment of stress urinary incontinence: a randomized controlled trial

Obstet Gynecol

(2008)

P.M. Latthe et al.

Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications

Br J Obstet Gynaecol

(2007)

Cited by (39)

Predictors of cure and overactive bladder syndrome after a mid-urethral sling procedure in women with stress urinary incontinence
2022, Maturitas
To determine predictive factors for the cure of stress urinary incontinence (SUI) or persisting or de novo overactive bladder syndrome (OAB) after a mid-urethral sling procedure (MUS) for women with SUI, especially for menopausal women.
All women who had consecutively received MUS for SUI between January 2008 and July 2019 in a tertiary referral center were reviewed.
Multivariable Cox proportional hazards model or logistic regression analysis was used to assess the predictors of cure and persisting or de novo OAB after MUS.
A total of 385 women had undergone MUS, of whom 265 (68.8%) were menopausal. The multivariable Cox proportional hazards model revealed that age (hazard ratio = 1.04), and preoperative detrusor overactivity (hazard ratio = 2.26) were independent predictors of persisting/recurrent SUI. Among the 216 women with preoperative OAB, 109 (50.5%) experienced resolution of their OAB after MUS; and among 169 women without preoperative OAB, twenty-five (14.8%) women developed de novo OAB after MUS (p < 0.0001). Preoperative OAB (hazard ratio = 3.97), small voided volume (hazard ratio = 0.83), and preoperative detrusor overactivity (hazard ratio = 1.62) were predictors of postoperative OAB. In addition, six (1.6%) women had mesh extrusion. Parity (odds ratio = 2.08) was the sole predictor of mesh extrusion. Menopause (hazard ratio = 1.69) was a predictor of postoperative OAB in the univariate analysis. However, menopause was not a predictor of cure or OAB in the multivariable analysis.
Age and preoperative detrusor overactivity were independent predictors of persisting/recurrent SUI. In addition, preoperative OAB, small voided volume, and preoperative detrusor overactivity were predictors of postoperative OAB. These findings could serve as a guide for preoperative consultation for MUS.
Predictors of further anti-incontinence interventions or transvaginal urethrolysis after a pubovaginal sling procedure in women with and without neurologic disorders
2021, Journal of the Formosan Medical Association
The impact of neurologic disorders on the clinical outcome of suburethral sling procedures has seldom been studied. Our aim is to elucidate factors predicting further anti-incontinence interventions or transvaginal urethrolysis after a re-adjustable pubovaginal sling procedure (PVS), especially in patients with neurologic disorders.
Medical records of all consecutive women who underwent re-adjustable PVS for stress urinary incontinence (SUI) were reviewed.
A total of 589 women were enrolled, 152 (25.8%) women were found to have persistent or recurrent SUI after surgery, and 39 (6.6%) women underwent further anti-incontinence interventions. Postoperative voiding dysfunction was found in 46 (7.8%) women, and 23 women (3.9%) underwent transvaginal urethrolysis. Low body mass index (hazard ratio = 0.92) and low functional bladder capacity (dL, hazard ratio = 0.83) were factors predicting the presence of persistent/recurrent SUI. However, the presence of spinal cord disorder (hazard ratio = 8.91) and a history of prior surgery for pelvic organ prolapse (hazard ratio = 2.51) were factors predicting further anti-incontinence interventions. A high post-void residual volume (PVR, dL, hazard ratio = 1.52) and preoperative bladder outlet obstruction (BOO, hazard ratio = 5.39) were factors predicting postoperative voiding dysfunction. Similarly, a high PVR (dL, hazard ratio = 1.50) and preoperative BOO (hazard ratio = 5.38) were factors predicting transvaginal urethrolysis. A PVR >1.51 dL was an optimal cut-off value for predicting transvaginal urethrolysis.
The presence of spinal cord disorder and prior surgery for pelvic organ prolapse were predictors of further anti-incontinence interventions after re-adjustable PVS. In addition, a large PVR and preoperative BOO were predictors of transvaginal urethrolysis after re-adjustable PVS.
Is single incision midurethral sling effective in patients with low maximal urethral closure pressure?
2016, Taiwanese Journal of Obstetrics and Gynecology
Citation Excerpt :
However, very few patients had MUCP of < 20 cmH2O. Since women with LUCP have been associated with the increased failure of incontinence surgery [8,9], and a low MUCP of < 42 cmH2O [10] and < 40 cmH2O [11] have been found to be significant risk factors affecting the treatment outcome, we categorized patients using a cut-off MUCP value of 40 cmH2O to define low urethral closure for the purpose of this study. Although this grouping does not follow the standard outlined by the ICS, the observations made in comparing the two patient groups remain valuable.
To ascertain whether low preoperational maximal urethral closure pressure (MUCP) affects the outcomes of single incision sling (SIS) procedures and changes MUCP values postsurgery.
There were 112 (MUCP ≥ 40 cmH₂O, n = 88; MUCP < 40 cmH₂O, n = 24) consecutive women with urodynamic stress incontinence who had undergone SIS (MiniArc) procedures included in this study. The threshold of 40 cmH₂O was used since it has been shown to be a significant risk factor for failed incontinence surgery. Clinical outcomes were assessed by the cough stress test, the 1-hour pad test, the Incontinence Impact Questionnaire-Short Form, the Urogenital Distress Inventory six-item questionnaire, the Sexual Questionnaire-SF, and postoperative changes in the urodynamic parameters. A comparison of the 1-year follow-up data is presented.
Three months postsurgery, a significant decrease was observed in the 1-hour pad test, from 20.6 g preoperatively to 0.73 g postoperatively (p < 0.001). The objective cure rate was 82.1% without any significant differences between the two groups (p = 0.202). At 3 months and 1 year after surgery, significantly decreasing Urogenital Distress Inventory six-item questionnaire and Incontinence Impact Questionnaire-Short Form, and increasing Sexual Questionnaire-SF scores were observed in both groups, without any significant differences between the two groups. No statistically significant difference in the subjective cured rate was noted between the two groups at the 3-month and 18.4 month follow-ups. The postoperative MUCP was significantly decreased in the MUCP ≥ 40 group (p < 0.05) while significantly increased in the MUCP < 40 group (p = 0.006).
These results suggest that SIS is a safe and highly effective treatment for urodynamic stress incontinence even in women with low MUCP at a mean follow-up of 18.4 months. Evaluation of the outcomes with more subjects after a longer follow-up period is necessary.
Intrinsic sphincter deficiency and female urinary incontinence
2015, Progres en Urologie
L’insuffisance sphinctérienne (IS) et l’hypermobilité urétrale sont les causes essentielles de l’incontinence urinaire à l’effort (IUE) féminine. Malgré l’absence de définition consensuelle dans la littérature, l’IS doit être finement évaluée pour être correctement traitée. Le but de ce travail est de faire une mise au point sur l’insuffisance sphinctérienne de la femme (ISF).
Il s’agit d’un travail de synthèse du CUROPF après analyse des articles publiés dans la base de données Medline (Pubmed) sélectionnés selon leur pertinence scientifique, des conférences de consensus et des recommandations publiées sur le sujet.
Même s’il n’existe pas de définition internationale consensuelle, on peut considérer que l’ISF est une notion composite associant des données urodynamiques (PCUM < 20 ou 30 cmH₂0) et une ou plusieurs données cliniques (absence de mobilité urétrale, test de soutènement urétral négatif, échec d’une première chirurgie, fuites à la poussée abdominale, scores d’incontinence à l’effort élevés). L’imagerie peut apporter des éléments supplémentaires en faveur du diagnostic d’insuffisance sphinctérienne, mais la corrélation entre l’imagerie et la fonction reste modeste. Le traitement chirurgical de première intention peut être l’implantation d’une bandelette sous-urétrale (BSU), de préférence rétropubienne, si les manœuvres de soutènement de l’urètre sont positives et que la contractilité vésicale est correcte. En l’absence de mobilité urétrale, le sphincter urinaire artificiel (SUA) reste le gold standard. Les ballons ACT^® sont une alternative au SUA lorsque celui-ci est contre-indiqué ou refusé par la patiente. La thérapie cellulaire est encore du domaine de la recherche clinique. La place des agents de comblement péri-urétraux n’est pas clairement définie. L’IS chez la femme âgée nécessite une attention particulière en raison de la fréquence de l’hypocontractilité vésicale et des comorbidités liées au vieillissement. Une évaluation gériatrique peut être nécessaire.
Il est important de reconnaître une IS lors de la prise en charge de l’IUE féminine afin d’en informer les patientes et de proposer les options thérapeutiques les mieux adaptées à chaque cas.
Stress urinary female incontinence (SUI) is primary due to intrinsic sphincter deficiency (ISD) and urethral hypermobility. Despite a lack of standardised international definition, ISD needs to be clearly diagnosed in order to be correctly treated. This work is an update about the female ISD produced from a review of a published article.
This review of article published on this subject in the Medline (Pubmed database), selected according to their scientific relevants, of consensus conferences and published guidelines, has been performed by the committee for women pelvic floor surgery of the French Urological Association.
Although there is no international consensus definition, we can consider that the ISD is a composite concept combining urodynamic data (MUCP < 20 or 30 cmH₂0) and one or more clinical information (no urethral mobility, negative urethral support test, failure of a first surgery, leakage during abdominal straining, high stress incontinence scores). Imaging can provide additional evidence for intrinsic sphincter deficiency diagnosis, but the correlation between imaging and function remains low. By standardizing methodology and interpretations to better diagnose women with ISD, it may be possible to improve preoperative planning and outcomes for these patients. A retropubic midurethral sling can be performed as a first surgery. In case of a lack of urethral mobility, the artificial urinary sphincter (AUS) remains the gold standard. Adjustable continence therapy (ACT^®) can be proposed as an alternative option. The efficacy and safety of muscle-derived cell therapy in ISD needs more studies. Injection of bulking agents may be an option according to the severity and the expectations of the patient. Bladder overactivity needs to be treated as first-line in case of mixed urinary incontinence. In elderly women, a careful evaluation of the bladder contractility and comorbidity must be performed. A geriatric evaluation can be necessary.
Clinical and paraclinical assessment allow to confirm the diagnosis of female ISD, to estimate its severity, and to identify associated mechanisms of incontinence (urethral hypermobility, bladder overactivity) to choose the most adapted treatment.
Review on midurethral sling procedures for stress urinary incontinence
2015, Gynecology and Minimally Invasive Therapy
Citation Excerpt :
Richter et al36 found risk factors for overall failure were previous SUI operation, Q-tip test <30°, severity of urge symptoms, and a high preoperative pad weight. Hsiao et al37 concluded that risk factors for recurrence can be the preoperative detrusor overactivity after TVT, lower maximal urethral pressure and < 40 cm H2O after TOT. Similar results by Houwert et al38 in a retrospective cohort study determined the low maximal urethral closure pressure and mixed UI as risk factors for failure after TOT.
Minimally invasive suburethral slings, namely the retropubic suburethral sling or the tension-free vaginal tape (TVT), has become the mainstay for surgical management of moderate to severe stress urinary incontinence (SUI) taking over the place of Burch's colposuspension after its introduction in the 1990s. Following the introduction of retropubic sling procedures are the transobturator (TVT-O) procedures and the mini-sling procedures. This review attempts to summarize the current trend of midurethral sling (MUS) procedures in the management of SUI.
Baseline urodynamic predictors of treatment failure 1 year after mid urethral sling surgery
2011, Journal of Urology
We determined whether baseline urodynamic study variables predict failure after mid urethral sling surgery.
Preoperative urodynamic study variables and postoperative continence status were analyzed in women participating in a randomized trial comparing retropubic to transobturator mid urethral sling. Objective failure was defined by positive standardized stress test, 15 ml or greater on 24-hour pad test, or re-treatment for stress urinary incontinence. Subjective failure criteria were self-reported stress symptoms, leakage on 3-day diary or re-treatment for stress urinary incontinence. Logistic regression was used to assess associations between covariates and failure controlling for treatment group and clinical variables. Receiver operator curves were constructed for relationships between objective failure and measures of urethral function.
Objective continence outcomes were available at 12 months for 565 of 597 (95%) women. Treatment failed in 260 women (245 by subjective criteria, 124 by objective criteria). No urodynamic variable was significantly associated with subjective failure on multivariate analysis. Valsalva leak point pressure, maximum urethral closure pressure and urodynamic stress incontinence were the only urodynamic variables consistently associated with objective failure on multivariate analysis. No specific cut point was determined for predicting failure for Valsalva leak point pressure or maximum urethral closure pressure by ROC. The lowest quartile (Valsalva leak point pressure less than 86 cm H₂O, maximum urethral closure pressure less than 45 cm H₂O) conferred an almost 2-fold increased odds of objective failure regardless of sling route (OR 2.23, 1.20–4.14 for Valsalva leak point pressure and OR 1.88, 1.04–3.41 for maximum urethral closure pressure).
Women with a Valsalva leak point pressure or maximum urethral closure pressure in the lowest quartile are nearly 2-fold more likely to experience stress urinary incontinence 1 year after transobturator or retropubic mid urethral sling.

View all citing articles on Scopus

View full text

Female UrologyRisk Factors Affecting Cure After Mid-urethral Tape Procedure for Female Urodynamic Stress Incontinence: Comparison of Retropubic and Transobturator Routes

Objectives

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Conclusions

Acknowledgment

Eur Urol

Eur Urol

Eur Urol

Urology

Eur J Obstet Gynecol Reprod Biol

J Urol

J Urol

Am J Obstet Gynecol

J Urol

J Urol

Urology

Intravaginal slingplasty (IVS): An ambulatory surgical procedure for treatment of female urinary incontinence

Scand J Urol Nephrol

Bandelette transobturatrice: un procédé mini-invasif pour traiter l'incontinence urinaire de la femme

Prog Urol

Transobturator tape compared with tension-free vaginal tape for the treatment of stress urinary incontinence: a randomized controlled trial

Obstet Gynecol

Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications

Br J Obstet Gynaecol

Female Urology
Risk Factors Affecting Cure After Mid-urethral Tape Procedure for Female Urodynamic Stress Incontinence: Comparison of Retropubic and Transobturator Routes