The prevalence of stress urinary incontinence (SUI) is 46% in women of reproductive age in Turkey. Because of the common etiology, it is not surprising that almost half of the women with SUI underwent additional pelvic surgeries with incontinence surgeries. Nevertheless, there is currently no consensus regarding the surgical treatment of SUI in patients who require concomitant surgical procedures for pelvic organ prolapse or benign uterine pathologies.
Several studies reported high cure rates in patients with SUI and genital prolapse after transobturator tape (TOT) and Burch colposuspension procedures along with pelvic reconstructive surgeries. Single-incision sling (SIS) procedure could also be performed with concomitant pelvic reconstructive surgery but data are scarce. Most of the studies that reported results of SIS procedure in patients with SUI excluded the patients with pelvic prolapse. This is the first study that reports the surgical outcomes of SIS and compares three different procedures to treat SUI in patients who underwent concomitant pelvic surgeries.
In this retrospective cohort study, we evaluated women with SUI or stress-predominant mixed urinary incontinence who underwent Burch colposuspension (n: 43), TOT (n: 40), or SIS (n:39) procedures along with pelvic reconstructive surgery or hysterectomy within eight years of time. Burch colposuspension was performed as originally described1, the TOT procedure was performed according to Delorme2 which is an outside to inside method. The SIS procedure was performed by using DynaMesh®-SIS minor, which is a nonabsorbable, fluoropolymer, polyvinylidene fuoride (PVDF) sling. After performing the sharp bilateral paraurethral dissection up to bilateral pubic rami, DynaMesh®-SIS minor was attached by a self-attaching surface without any additional fixation device.
We evaluated all patients at one, six, 12 months, and annually after the surgical interventions and recorded any symptom that was relevant to the procedures and outcomes of patient-reported Turkish language–validated versions of questionnaires.
We found a higher sling extrusion rate in the SIS group than in the TOT group [six cases (15.4%) vs two cases (5.15%), p = 0.008]. Bladder injury and voiding dysfunction rates were similar among the groups. The objective cure rates were higher in Burch and TOT groups than in the SIS group (53.5%, 65%, and 30.85% in Burch, TOT, and SIS groups, respectively, p = 0.008). Surgical success rates were higher in Burch and TOT groups than in SIS group (88.4%, 87.5%, and 61.5% in Burch, TOT, and SIS groups, respectively, p=0.003). There was no statistical significance between Burch and TOT groups in terms of objective cure, subjective cure, improvement, failure, and surgical success rates. The complaints of urinary incontinence were higher, whereas the quality of life was lower in the SIS group than in the Burch group. Incontinence impact questionnaire (IIQ-7), urogenital distress inventory (UDI-6), overactive bladder questionnaire V8 (OAB-V8), and Sandvik severity index (SSI) scores were significantly higher in the SIS group than in the Burch group.
While results of SUI procedures with newer SIS seems promising and many studies reported that TOT and SIS had comparable cure rates, contrary to these studies, we found an inferior cure (46.2%) and surgical success (61.5%) rates, and higher failure (38.5%) rates in the SIS (DynaMesh® SIS minor) group than both Burch and TOT groups in our study. Inferiority was not observed between Burch and TOT groups. However, we recommend that the results of our study need a careful interpretation. The material of the SIS was PVDF which is a non-absorbable, fluoropolymer monofilament, and it is different from the other studies (that most commonly used polypropylene). There is a paucity of data in the literature regarding the use of PVDF slings in urinary incontinence procedures. Currently, there are no studies that compare PVDF with polypropylene SIS.
In summary, we found that Burch colposuspension and TOT procedures were more efficacious than SIS (DynaMesh® SIS minor) procedure in patients with SUI who also underwent combined pelvic reconstructive surgery or hysterectomy. The quality of life scores were also higher in patients who underwent Burch colposuspension or TOT procedures than in the patients who underwent SIS (DynaMesh® SIS minor) procedure. Although the surgical outcome of SIS (DynaMesh® SIS minor) procedure in SUI patients who underwent concomitant pelvic surgeries in our study was not promising as resulted in high sling extrusion rates and low cure rates, further studies with PVDF sling are needed to clarify these observations.
Written by: Yesim Akdemir, MD, Assistant Professor, Obstetrics and Gynecology Department, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
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- Delorme, Emmanuel. "Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women." Progres en urologie: journal de l'Association francaise d'urologie et de la Societe francaise d'urologie 11, no. 6 (2001): 1306-1313.