Mini-sling efficacy in obese versus non-obese patients for treatment of stress urinary incontinence: Beyond the Abstract

The impact of obesity on anti-incontinence surgery has been object of concerns. BMI has been demonstrated to significantly affect intra-abdominal pressure, suggesting that obesity may increase stress on anti-incontinence devices [1].

However evidences show that both retropubic and transobturator tapes have similar efficacy and perioperative safety in obese patients compared to normal weight women [2]. While good evidence is available on this topic for standard midurethral slings, there are few and conflicting data for single-incision slings (SIS). SIS are an attractive alternative to standard midurethral slings, as they showed comparable efficacy with less pain and recovery time [3]. However concerns have been raised that the reduced surface area of SIS may be inadequate to hold in place the tape against an higher intra-abdominal pressure [4]. These concerns are related to the absence of groin-fixation, the decreased surface of mesh and the unknown biomechanical performance of the self-fixating tips. 

To the best of our knowledge, only three studies are available on this topic. Meschia et al. retrospectively analyzed effects of BMI in a cohort of patients at 1 year after either TVT-secur or Ajust. They found that patients with BMI >30 had a lower objective cure rate and ICIQ-SF score improvement compared to normal /overweight women [5]. In a retrospective study Anding et al. analyzed a series of patients after Ajust procedure and showed greater reduction in pads usage per day in women with a BMI <30. No significant differences were found with regards to patients’ satisfaction [6]. On the other hand, Moore et al. demonstrated in a prospective study no significant differences in objective and subjective cure rate of Miniarc procedure between obese and non-obese patients [4]. 

A possible explanation for these contrasting findings can be found in the different anti-incontinence procedures performed and devices used. Analyzed kits have some substantial differences. While Miniarc is a non-adjustable system, Ajust is fully-adjustable. In addition they have different self-fixating anchoring systems, which may significantly affect biomechanical resistance [7]. Lastly, the efficacy of Miniarc fixation system seems to be maintained irrespective of bilateral anchorage to obturator membranes [8]. It can be speculated that Miniarc peculiar characteristics may imply higher resistance to tape displacement in case of increased intra-abdominal pressures. This can obviously be of great importance in obese patients. 

Our study confirmed that single-incision sling Miniarc seems to be an effective treatment irrespective of BMI. Objective, subjective and functional outcomes were similar for normal weight, overweight and obese women. The procedure could be easily completed in obese patients unless increasing operative time, bleeding or complications. SIS Miniarc may be considered as an effective procedure when counselling obese women. 

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Written By: Frigerio M, Manodoro S.

References

[1] Noblett KL, Jensen JK, Ostergard DR. The relationship of body mass index to intra-abdominal pressure as measured by multichannel cystometry. Int Urogynecol J Pelvic Floor Dysfunct. 1997;8(6):323-6.

[2] Weltz V, Guldberg R, Lose G. Efficacy and perioperative safety of synthetic mid-urethral slings in obese women with stress urinary incontinence. Int Urogynecol J. 2015 May;26(5):641-8. 

[3] Mostafa A, Lim CP, Hopper L, Madhuvrata P, Abdel-Fattah M. Single-incision mini-slings versus standard midurethral slings in surgical management of female stress urinary incontinence: an updated systematic review and meta-analysis of effectiveness and complications. Eur Urol. 2014 Feb;65(2):402-27. 

[4] Moore RD, De Ridder D, Kennelly MJ. Two-year evaluation of the MiniArc in obese versus non-obese patients for treatment of stress urinary incontinence. Int J Urol. 2013 Apr;20(4):434-40. 

[5] Meschia M, Rossi G, Bertini S et al. Eur J Obstet Gynecol Reprod Biol. 2013 Oct;170(2):571-4. Single incision mid-urethral slings: impact of obesity on outcomes.

[6] Anding R, Schoen M, Kirschner-Hermanns R, Fisang C, Müller SC, Latz S. Minimally invasive treatment of female stress urinary incontinence with the adjustable single-incision sling system (AJUST ™) in an elderly and overweight population. Int Braz J Urol. 2017 Jan 27;43. [Epub ahead of print]

[7] Palma P, Siniscalchi RT, Maciel LC, Bigozzi MA, Dal Fabbro I, Riccetto C. Primary fixation of mini slings: a comparative biomechanical study in vivo. Int Braz J Urol. 2012 Mar-Apr;38(2):258-65; discussion 265-6.

[8] Spelzini F, Cesana MC, Verri D, Polizzi S, Frigerio M, Milani R. Three-dimensional ultrasound assessment and middle term efficacy of a single-incision sling. Int Urogynecol J. 2013 Aug;24(8):1391-7.
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