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Mixed urinary incontinence: A prospective study on the effect of trans-obturator mid-urethral sling

Published:December 06, 2017DOI:https://doi.org/10.1016/j.ejogrb.2017.12.003

      Abstract

      Objectives

      It is hypothesized that urethral dysfunction is central in mixed urinary incontinence (MUI) in women, since urine entering the proximal urethra under increased intra-abdominal pressure provokes a urethro-detrusorial reflex and involuntary detrusor contraction. Mid-urethral slings have been proposed as a solution. Our primary objective was to evaluate the long-term subjective and objective outcomes on continence and other urinary symptoms of a trans-obturator mid-urethral sling (TOT) procedure. Our secondary objectives were to determine its impact on quality of life (QoL), and to investigate which factors influence outcomes.

      Study design

      This is a single-centre prospective study on a consecutive series of 86 women who underwent TOT for MUI as defined by ICS/IUGA. Since the definition of MUI that we used is symptom-based, we included patients both with and without associated detrusor overactivity. All patients underwent placement of Monarc® Subfascial Hammocks.

      Statistical analysis

      We used the McNemar chi-square test, the paired t-test and Fisher’s exact test. A logistic regression model and odds ratios were used to assess age, parity, body mass index, menopausal status, preoperative detrusor over-activity, and detrusor pressure at maximum flow as possible factors for treatment failure. Only those that were statistically significant in the univariate analysis were included in the multivariate analysis.

      Results

      With a mean follow-up of 59 months, SUI was cured objectively in 83.7% of patients and subjectively in 87.2%. Three patients underwent further anti-incontinence surgery. The continence rates were 74.4% for urgency urinary incontinence (UUI) and 66.3% for SUI-UUI. The patient-reported success rate was 87.2% (‘much better’ or ‘very much better’ on Patient Global Impression of Improvement scale). There were statistically significant improvements in all domains except general health. The univariate analysis found no significant risk factor for persistence of SUI. Median age >60 years and menopause were predictive for persistence of UUI. Median and mean age >60 years were predictive of persistence of overall incontinence. In the multivariate model, all variables lost their statistical significance.

      Conclusion

      Our study demonstrates TOT surgery can be performed for patients with MUI following unsuccessful conservative therapy. We also demonstrate that menopause and age >60 are risk factors for failure. This should be considered when counselling preoperatively.

      Keywords

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      References

        • Haylen B.T.
        • de Ridder D.
        • Freeman R.M.
        • Maher C.
        • Haylen B.
        • Athanasiou S.
        • et al.
        An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction.
        Int Urogynecol J. 2010; 21: 5-26
        • Karram M.M.
        • Bhatia N.N.
        Management of coexistent stress and urge urinary incontinence.
        Obstet Gynecol. 1989; 73: 4-7
        • Coyne K.S.
        • Zhou Z.
        • Thompson C.
        • Versi E.
        The impact on health-related quality of life of stress, urge and mixed urinary incontinence.
        BJU Int. 2003; 92: 731-735
        • Khullar V.
        • Cardozo L.
        • Dmochowski R.
        Mixed incontinence: current evidence and future perspectives.
        Neurourol Urodyn. 2010; 29: 618-622
        • Gomelsky Α.
        • Dmochowski R.
        Treatment of mixed urinary incontinence in women.
        Curr Opin Obstet Gynecol. 2011; 23: 371-375
        • Artibani W.
        Difficult to manage patient populations: mixed symptomatology.
        BJU Int. 2000; 85: 53-54
        • Jung S.Y.
        • Fraser M.O.
        • Ozawa H.
        • Yokoyama O.
        • Yoshiyama M.
        • De Groat W.C.
        • et al.
        Urethral afferent nerve activity affects the micturition reflex; implication for the relationship between stress incontinence and detrusor instability.
        J Urol. 1999; 162: 204-212
        • Jain P.
        • Jirschele K.
        • Botros S.M.
        • Latthe P.M.
        Effectiveness of midurethral slings in mixed urinary incontinence: a systematic review and meta-analysis.
        Int Urogynecol J. 2011; 22: 923-932
        • Bump R.C.
        • Mattiasson A.
        • Bo K.
        • Brubaker L.P.
        • DeLancey J.O.
        • Klarskov P.P.
        • et al.
        The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction.
        Am J Obstet Gynecol. 1996; 175: 10-17
        • Artibani W.
        • Pesce F.
        • Prezioso D.
        • Scarpa R.M.
        • Zattoni F.
        • Tubaro A.
        • et al.
        Italian validation of the urogenital distress inventory and its application in LUTS patients.
        Eur Urol. 2006; 50: 1323-1329
        • Kelleher C.J.
        • Cardozo L.D.
        • Khullar V.
        • Salvatore S.
        A new questionnaire to assess the quality of life of urinary incontinent women.
        Br J Obstet Gynaecol. 1997; 104: 1374-1379
        • Yalcin I.
        • Bump R.C.
        Validation of two global impression questionnaires for incontinence.
        Am J Obstet Gynecol. 2003; 189: 98-101
        • Ingelmann-Sundberg A.
        • Ulmsten U.
        Surgical treatment of female urinary stress incontinence.
        Contrib Gynecol Obstet. 1983; 10: 51-69
        • Blaivas J.G.
        • Groutz A.
        Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology.
        Neurourol Urodyn. 2000; 19: 553-564
        • Irwin D.E.
        • Milsom I.
        • Chancellor M.B.
        • Koop Z.
        • Guan Z.
        Dynamic progression of overactive bladder and urinary incontinence symptoms: a systematic review.
        Eur Urol. 2010; 58: 532-543
        • Deffieux X.
        • Donnadieu A.C.
        • Porcher R.
        • Gervaise A.
        • Frydman R.
        • Fernandez H.
        Long-term results of tension-free vaginal tape for female urinary incontinence: follow up over 6 years.
        Int J Urol. 2007; 14: 521-526
        • Rezapour M.
        • Ulmsten U.
        Tension-Free vaginal tape (TVT) in women with mixed urinary incontinence—a long-term follow-up.
        Int Urogynecol J Pelvic Floor Dysfunct. 2001; 12: S15-S18
        • Paick J.S.
        • Oh S.J.
        • Kim S.W.
        • Ku J.H.
        Tension-free vaginal tape, suprapubic arc sling, and transobturator tape in the treatment of mixed urinary incontinence in women.
        Int Urogynecol J Pelvic Floor Dysfunct. 2008; 19: 123-129
        • Kocjancic E.
        • Costantini E.
        • Frea B.
        • Crivellaro S.
        • Degiorgi G.
        • Tosco L.
        • et al.
        Tension free vaginal tape vs trans obturator tape: is there any difference in the mixed incontinence patients? Results of multicentre randomized trial.
        Eur Urol. 2008; (abstr 209): 123
        • Abdel-Fattah M.
        • Hopper L.R.
        • Mostafa A.
        Evaluation of transobturator tension-free vaginal tapes in the surgical management of mixed urinary incontinence: 3-year outcomes of a randomized controlled trial.
        J Urol. 2014; 191: 114-119
        • Rinne K.
        • Laurikainen E.
        • Kivelä A.
        • Aukee P.
        • Takala T.
        • Valpas A.
        • et al.
        A randomized trial comparing TVT with TVT-O: 12-month results.
        Int Urogynecol J Pelvic Floor Dysfunct. 2008; 19: 1049-1054
        • Porena M.
        • Costantini E.
        • Frea B.
        • et al.
        Tension-free vaginal tape versus transobturator tape as surgery for stress urinary incontinence: results of a multicentre randomised trial.
        Eur Urol. 2007; 52: 1481-1490
        • Meschia M.
        • Bertozzi R.
        • Pifarotti P.
        • Baccichet R.
        • Bernasconi F.
        • Guercio E.
        • et al.
        Peri-operative morbidity and early results of a randomised trial comparing TVT and TVT-O.
        Int Urogynecol J Pelvic Floor Dysfunct. 2007; 18: 1257-1261
        • Barber M.D.
        • Kleeman S.
        • Karram M.M.
        • Paraiso M.F.
        • Walters M.D.
        • Vasavada S.
        • et al.
        Transobturator tape compared with tension-free vaginal tape for the treatment of stress urinary incontinence: a randomized controlled trial.
        Obstet Gynecol. 2008; 111: 611-621
        • Richter H.E.
        • Albo M.E.
        • Zyczynski H.M.
        • Kenton K.
        • Norton P.A.
        • Sirls L.T.L.T.
        • et al.
        Retropubic versus transobturator midurethral slings for stress incontinence.
        N Engl J Med. 2010; 362: 2066-2076
        • Abdel-Fattah M.
        • Cao G.
        • Mostafa A.
        Long-term outcomes for transobturator tension-free vaginal tapes in women with urodynamic mixed urinary incontinence.
        Neurourol Urodyn. 2017; 36: 902-908
        • Lee G.B.
        • Kim H.S.
        • Koh J.S.
        • Kim H.W.
        • Lee Y.S.
        • Suh H.J.
        • et al.
        The changes of storage symptoms after tension-free vaginal tape procedures in stress urinary incontinence patients.
        Korean J Urol. 2007; 48: 1289-1295
        • Hashim H.
        • Abrams P.
        Is the bladder a reliable witness for predicting detrusor overactivity.
        J Urol. 2006; 175: 191-194
        • Athanasiou S.
        • Grigoriadis T.
        • Giannoulis G.
        • Protopapas A.
        • Antsaklis A.
        Midurethral slings for women with urodynamic mixed incontinence: what to expect.
        Int Urogynecol J. 2013; 24: 393-399
        • Petros P.E.
        • Ulmsten U.
        Bladder instability in women: a premature activation of the micturition reflex.
        Neurourol Urodyn. 1993; 12: 235-239