NSAUA 2018: Evaluation and Management of Women with Recurrent Stress Urinary Incontinence

Toronto, Ontario (UroToday.com) The topic of recurrent stress urinary incontinence after initial surgical therapy in women was discussed in this talk by E. Ann Gormley, MD. In recurrent stress urinary incontinence (SUI) the severity of the incontinence occurring following a failed surgery can either be the same or might even be worse. This entity of recurrent SUI after initial failed surgical therapy can be divided into several entities:

1. Persistent (early, never experienced dryness) SUI  
2. Recurrent (initial success and then failure) SUI
3. Patient desires additional treatment
4. Persistent deNovo urge
5. Development of a fistula

Another option is that the SUI is treated successfully, but there is a complication which can be manifested as a mesh complication or difficulty with voiding/obstruction.

SSI surgical failure can be defined in a more flexible manner, using the surgeons/patient’s assessment of cure on the last follow-up visit, or using the strict definition which includes an objective and subjective component of assessment at a minimum follow-up of 12 months.

According to the American Urologic Association (AUA) guidelines, mid urethral slings (MUS) with the insertion of a mesh, have comparable efficacy to autologous slings (pubovaginal or fascial slings). Usage of MUS entails more rapid recovery and more efficient return to normal voiding. The rare complication of mesh extrusion should be avoided by using intraoperative cystoscopy to examine the bladder and urethra and minimize the risk of urinary tract injury.

Not all the slings are the same, and not all MUS is the same. They all differ in their treatment success rates and complications rates. Contemporary data demonstrate that MUS is the mainstay first line treatment for SUI. MUS can perform either as a retropubic MUS (RMUS) or as a transobturator (TMUS) approach. RMUS has 13.8% failure rate after a follow-up of 94 months. The TMUS has a failure rate of 31-36% at 10 years follow-up.

In The Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr)1, Burch colposuspension (Burch colposuspension (a procedure used to treat urinary incontinence due to pelvic floor relaxation. It entails the attachment of the paravaginal fascia to Cooper's ligament), and autologous rectus fascial sling were analyzed. Between 34-51% of the patients had failed. In the 5-Year Longitudinal Follow-up after Retropubic and Transobturator Midurethral Slings (ToMUS) study2 the failure rate was 20-44%. However, only 48 patients from both trials were retreated.

The risk factors for MUS failure include BMI >25, mixed incontinence, prior SUI surgery, intrinsic sphincter deficiency (ISD), and diabetes.3 Importantly, to evaluate these women:

  • A complete history needs to be taken - physicians need to understand the onset of SUI, severity, and characterization of symptoms
  • All historical records need to be reviewed
  • Complete physical examination needs to be performed - urethral mobility should be assessed; a stress test should be performed, while other vaginal pathology should be assessed. Scars should be noted, and pain, tenderness or numbness associated with a previous sling should be assessed
  • Urinalysis and culture need to be done0
  • Post-void residual test
  • Cystoscopy - performed to discover prior mesh in the urethra and bladder
  • Urodynamic studies - Should be able to demonstrate the incontinence, mobility and ISD, assess compliance/ capacity of the bladder, and inform us if there is a potential obstruction
According to the AUA guidelines, additional evaluation should be performed when there is a lack in the definitive diagnosis, inability to demonstrate SUI, known Neurogenic lower urinary tract dysfunction (NLUTD), abnormal urinalysis, elevated post-void residual, high grade pelvic organ prolapse, and urge incontinence predominantly mixed incontinence.4 Additional tests may be performed in patients with concomitant overactive bladder symptoms, failure of prior anti-incontinence surgery, and prior pelvic organ prolapse. An ultrasound examination can also be done to identify the mesh.

It is most important that urologists determine the reason for failure:  whether the wrong procedure was performed, wrong material (mesh) used, lacking technical surgical skills, some change that had occurred in the patents; and other miscellaneous reasons. The treatment consists of several options:

  • Conservative – wait and see approach, usage of various medications
  • Tightening of a prior sling – for pubovaginal sling this can be done up to 12 weeks following the initially failed procedure. For MUS – it is possible to plicate the mesh with a non-absorbable suture, resulting in cure in 47% of cases
  • A repeat MUS procedure – whether retropubic or obturator. Some data suggest that a retropubic approach may be superior to an obturator approach in redo procedures. A good candidate is a patient with healthy vaginal mucosa, and a mobile bladder neck and urethra. In a meta-analysis assessing the outcomes of MUS following MUS, the cure rate was 73.3%5. The question of what to do after a second failed MUS remains unanswered.
  • Fascial (Pubovaginal) sling procedure
  • Injectable sling –bulking agent
Dr. Gormley continued and discussed the role of fascial (pubovaginal) sling in the age of mesh synthetics. Historically, all patients were candidates for this procedure except those who couldn’t comply with the postoperative restrictions, who couldn’t perform self-catheterization, obese patients and those with limited vaginal access. It was a popular procedure, especially when it was performed concomitantly with prolapse repairs, augmentation, diverticulectomy, and following mesh removal or reconstruction. According to Dr. Gormley, this is reasonably a straightforward procedure which takes up to two hours, with less than 24 hours of postoperative hospital recovery. It should be offered as part of a comprehensive program, and its use has been increased following the FDA notifications warning about the use of mesh in MUS. The possible complications of this procedure include bleeding, retroperitoneal hematoma (less than 0.5% of cases), urinary retention or obstructed voiding, deNovo urge incontinence (10-20% of cases), urethral erosion (very rare), and wound issues (worse in obese patients). The advantages of this procedure include the fact that it is a simple, successful and durable procedure, using autologous tissue without any mesh, with minimal contraindications or complications.

What will determine what kind of procedure the surgeon will perform in patients who have failed initial SUI surgical treatment includes the patient’s expectations, her urethral mobility, urodynamic parameters, whether it is a complex case and the surgeon’s preference? Summing all available evidence, it is clear that we currently have minimal data on how to best treat patients following a failed MUS procedure. What we need are randomized controlled trials between retropubic MUS, transobturator MUS and pubovaginal sling.

In conclusion, failure of primary slings occurs in 12-44% of cases. The known predictors of failure include diabetes, obesity, mixed incontinence, ISD, prior surgery, increased age, and increased pad weight. A complete evaluation of these patients is needed, and randomized controlled trials are needed to provide us with clear answers on how to treat these patients in the best way.


Presented by: E. Ann Gormley, MD, Professor of Surgery in Urology, Dartmouth-Hitchcock Medical Center

References:
1. Tennstedt S et al. Urology 2005
2. Kenton K et al. J Urol 2015
3. Stav et al. Int Urogyn J 2010
4. Kobashi K et al. J Urol 2017
5. Pradhan et al. Int Urogyn 2012

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, @GoldbergHanan at the 70th Northeastern Section of the American Urological Association (NSAUA) - October 11-13, 2018 - Fairmont Royal York Toronto, ON Canada
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