Clinical audit
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Comparison of transobturator sling procedures for genuine stress urinary incontinence in the short to medium term

by Bernie Brenner
Pelvic Floor Clinic - Milford, Auckland (New Zealand)

Abstract: This report is a retrospective audit that compares the use of 3 different slings to treat stress incontinence using the transobturator approach in the hands of a single surgeon. There is a highly significant reduction in incontinence in all patients undergoing a transoburator sling. There was no difference in the short term and medium outcomes by objective and subjective assessment. The most common complication noted was urgency incontinence. Key words: Plastination, Stress incontinence, Transobturator, Outcomes, Complications.

INTRODUCTION

The suburethral sling has become the main operation for the surgical management of stress urinary incontinence in women. The transobturator approach for sling placement has gained popularity and the technique and variety of commercially available materials has been well covered in the literature.1 The effect on quality of life is also well documented.2

Complications with the use of multifilament mesh in terms of mesh erosion have been reported 3,4 but the use of monofilament or biological material has significantly decreased this problem. The availability of a variety of materials allows the surgeon a choice.5

Does it really matter which sling is used? This report is a short to medium term audit of the outcomes of patients who underwent a transobturator sling using a variety of materials but with all operations performed by the same surgeon.

MATERIALS AND METHODS

One hundred and thirty four patients who had genuine stress incontinence diagnosed by urodynamic studies underwent pre and post operative 1 hour pad tests, and ICS QOL questionnaire. A medium term retrospective audit was performed of all patients by telephone or email for subjective review.

The transobturator approach was used on all patients and the procedures were performed by the same surgeon between May 2004 and March 2007 using one of the three available slings. All the operations were performed as day stay surgery except when concurrent other gynaecological surgery was required or other risk factors required overnight observation. All procedures were performed under general anaesthesia and all patients had cystoscopy performed after tape placement.

The short term follow up on all patients was 6 weeks and the average medium term follow up was 22 months. Three types of sling were used. The Johnson and Johnson TVT Obturator System using polypropylene mesh (n=13), the AMS Monarc™ Transobturator polypropylene mesh (n=57) and the Bard Pelvicol™ Porcine mesh Transobturator placement (n=64). Objective data from the pre and post op pad tests were analysed using PH Stat and the t Test for differences in 2 means. The subjective data was converted to a digital scale and analysed in a similar fashion. All patients received peri-operative antibiotics.

RESULTS

Of the 134 patients with genuine stress urinary incontinence, a Transobturator sling was performed in all using one of three methods as described. Sixteen percent of patients underwent a concurrent other gynaecological procedure as well. These included in order of frequency, pelvic floor repair, hysterectomy and sacrospinous colpopexy.

The median age was 56 years (range 35-86, mean 56). The age distribution was similar for all groups. The objective results and the subjective results showed a very high degree of correlation. An assessment of the entire group showed that there was a marked improvement from the pre-operative state to the postoperative one both for the short and medium results and in both objective and subjective scores (p < .001, 95% CI). Assessing the results of the three groups separately, the Monarc™ and the Pelvicol™ groups had similar excellent results (p < .001, 95% CI). The TVT-Obturator™ also had excellent results but this was a smaller group (p = .002, 95% CI).

When any one method was compared with another there was found to be no significant difference in any one over the other. The most common short term complication was the de novo appearance of urgency and urgency incontinence. This occurred in 12 patients or 9% of the group. This symptom occurred with equal frequency across the three groups. In all cases the urgency had disappeared or was much better by medium term follow up. There were 5 cases of urinary tract infection post operatively making an overall rate of 3.7%. There were no erosions noted at short term follow up and no symptoms to suggest this as a problem at medium term. Patients did not undergo an examination at the medium term follow up.

DISCUSSION

Transobturator sling placement is a very successful procedure for the treatment of genuine stress urinary incontinence. The short to medium term results using both objective and subjective measures confirms its value in the modern management of stress incontinence. It has a low complication rate and is quick and easy to perform.

This retrospective audit includes all cases performed by one surgeon and allows the opportunity to compare three different Transobturator operations. It is clear that the results of the three procedures described above all give the same results when assessed in the short to medium term. From this perspective then it does not matter which procedure is used. They are all equally good. Long term follow up may however show some discriminating features.

REFERENCES

  1. Shindel AW, Klutke CG. Transobturator approach to suburethral sling placement in the treatment of stress urinary incontinence in women. Expert Rev Med Devices 2005; 2: 613-22.
  2. Plachta Z, Jankiewicz K, Skorupski P, Rechberger T. Quality of life after mid-urethra polypropylene tape sling surgery (IVS, TVT) in female stress urinary incontinence [in Polish]. Ginekol Pol 2003; 74: 986-91.
  3. Baessler K, Tunn R, Schuessler B, Maher CF. Severe Mesh Complications Following Intravaginal Slingplasty. Obstetrics & Gynecolog, 2005; 106: 713-716.
  4. Rechberger T, Skorupski P, Adamiak A, Tomaszewski J, Baranowski W. A randomized comparison between monofilament and multifilament tapes for stress incontinence surgery. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 432-6.
  5. Roth CC, Winters JC. Synthetic slings: which material, which approach. Curr Opin Urol 2006; 16: 234-9.

Correspondence: Dr. Bernie Brenner FRANZCOG
Pelvic Floor Clinic 131 Shakespeare Rd Milford, Auckland (New Zealand)
E-mail: gynaecology@xtra.co.nz

No external funding was used for this study.
Competing interests: None

EDITORIAL COMMENT

This paper is valuable because it reports the clinical outcomes of a series of all patients referred to and then operated by an experienced pelvic surgeon. We are constantly subjected to opinions regarding the validity of different sling materials and claims by manufacturers or champions of various products. Retrospective review of a group of patients such as this eliminates the bias and variations in surgeon experience that may affect the results of more formal controlled trials involving carefully selected groups of patients.