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383 Sonography tape characteristic and incontinence outcome after trans-obturator tape (TOT) surgery
383
Sonography tape characteristic and incontinence outcome after trans-obturator tape (TOT) surgery Eur Urol Suppl 2014;13;e383
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Costantini E., Salvini E., Pietropaolo A., Quadrini F., Di Biase M., Bini V., Del Zingaro M. Ospedale S. Maria Della Misericordia, Dept. of Urology, Perugia, Italy INTRODUCTION & OBJECTIVES: Tension-free vaginal transobturator tape (TOT) is currently one of the most effective and popular procedures for the surgical treatment of female stress urinary incontinence (SUI). However, 5-23% of patients will have persistent or recurrent urinary incontinence after surgery. Aim of the study was to evaluate in the long-term period if trans-perineal ultrasonography is able to recognize improper positioning or dislodgment of the tape or other factors that may be associated with failed surgery. MATERIAL & METHODS: Seventy-eight patients who underwent TOT from May 2002 to may 2006 in our clinic were recalled to perform a urological evaluation including clinical examination, incontinence outcome evaluation and ultrasound scan by trans-perineal approach. 51/78 patients had been included in a RCT designed to compare the safety and success rate of TVT and TOT, 27 performed TOT in the following 6 months. Only the patients who underwent TOT were included in this evaluation. Ultrasound was performed with the woman in the supine position, with a full comfortable bladder, at rest and then during maximum Valsalva manoeuvre using 3.5-5 MHz curved array probes. The ultrasound parameters evaluated are: a) the grade of urethrocele b)the position of the mesh along the urethra: 1) proximal to the bladder neck 2) midurethral position 3) distal position; c) the movement and the symmetry of the lateral arms of the mesh during straining and d) the presence or absence of an open bladder neck. On the basis of the incontinence outcome patients were allocated into two categories: dry vs wet (any kind or grade of leakage). Statistical analysis was performed by using a X2 and Mann Whitney test and multiple logistic regression analysis. RESULTS: Sixty-seven patients were evaluated (11 lost to follow-up) with a median follow-up of 100 months. 70,1% patients were completely dry. No difference in post-operative urethrocele evaluation and open bladder neck in continent and incontinent patients was present. Sling location at the distal urethral position could be related to a worst outcome as well as an asymmetry of the slings arms. Logistic regression analysis showed that age (OR 1.080; 95%C.I. 1.009-1.156; p=0.027) and symmetry of the mesh (OR 17.14; 95%C.I. 3.32-88.49; p=0.001) were correlated with the outcome. Also the position of the mesh was correlated with the outcome: in particular the midurethral (OR 0.068; 95%C.I.0.006-0.729; p=0.026) and proximal position (OR 0.068; 95%C.I. 0.012-0.403; p=0.003). The tape placement in both, proximal and midurethral locations, reduced the risk of failure by 14 folds as compared with the tape placement in the distal third of the urethra. CONCLUSIONS: Ultrasonography is a non invasive method that provides useful informations about the position and functional behaviour of the TOT sling at rest and during straining. A correct TOT positioning along the urethra seems to play a role in the incontinence outcome, so the correct surgical technique is mandatory to obtain the best results. Further studies are necessary to correlate pre-operative anatomical characteristics of the patients and the surgical technique. Not only the correct mid-urethral position but also the dynamic change in tape shape during straining is important. Furthermore the modification of these parameters at long-term follow-up should be evaluated to understand if the sling tends to move in the time or if other factors could affect its position.
Sonography tape characteristic and incontinence outcome after trans-obturator tape (TOT) surgery Eur Urol Suppl 2014;13;e383
Print! Print!
Costantini E., Salvini E., Pietropaolo A., Quadrini F., Di Biase M., Bini V., Del Zingaro M. Ospedale S. Maria Della Misericordia, Dept. of Urology, Perugia, Italy INTRODUCTION & OBJECTIVES: Tension-free vaginal transobturator tape (TOT) is currently one of the most effective and popular procedures for the surgical treatment of female stress urinary incontinence (SUI). However, 5-23% of patients will have persistent or recurrent urinary incontinence after surgery. Aim of the study was to evaluate in the long-term period if trans-perineal ultrasonography is able to recognize improper positioning or dislodgment of the tape or other factors that may be associated with failed surgery. MATERIAL & METHODS: Seventy-eight patients who underwent TOT from May 2002 to may 2006 in our clinic were recalled to perform a urological evaluation including clinical examination, incontinence outcome evaluation and ultrasound scan by trans-perineal approach. 51/78 patients had been included in a RCT designed to compare the safety and success rate of TVT and TOT, 27 performed TOT in the following 6 months. Only the patients who underwent TOT were included in this evaluation. Ultrasound was performed with the woman in the supine position, with a full comfortable bladder, at rest and then during maximum Valsalva manoeuvre using 3.5-5 MHz curved array probes. The ultrasound parameters evaluated are: a) the grade of urethrocele b)the position of the mesh along the urethra: 1) proximal to the bladder neck 2) midurethral position 3) distal position; c) the movement and the symmetry of the lateral arms of the mesh during straining and d) the presence or absence of an open bladder neck. On the basis of the incontinence outcome patients were allocated into two categories: dry vs wet (any kind or grade of leakage). Statistical analysis was performed by using a X2 and Mann Whitney test and multiple logistic regression analysis. RESULTS: Sixty-seven patients were evaluated (11 lost to follow-up) with a median follow-up of 100 months. 70,1% patients were completely dry. No difference in post-operative urethrocele evaluation and open bladder neck in continent and incontinent patients was present. Sling location at the distal urethral position could be related to a worst outcome as well as an asymmetry of the slings arms. Logistic regression analysis showed that age (OR 1.080; 95%C.I. 1.009-1.156; p=0.027) and symmetry of the mesh (OR 17.14; 95%C.I. 3.32-88.49; p=0.001) were correlated with the outcome. Also the position of the mesh was correlated with the outcome: in particular the midurethral (OR 0.068; 95%C.I.0.006-0.729; p=0.026) and proximal position (OR 0.068; 95%C.I. 0.012-0.403; p=0.003). The tape placement in both, proximal and midurethral locations, reduced the risk of failure by 14 folds as compared with the tape placement in the distal third of the urethra. CONCLUSIONS: Ultrasonography is a non invasive method that provides useful informations about the position and functional behaviour of the TOT sling at rest and during straining. A correct TOT positioning along the urethra seems to play a role in the incontinence outcome, so the correct surgical technique is mandatory to obtain the best results. Further studies are necessary to correlate pre-operative anatomical characteristics of the patients and the surgical technique. Not only the correct mid-urethral position but also the dynamic change in tape shape during straining is important. Furthermore the modification of these parameters at long-term follow-up should be evaluated to understand if the sling tends to move in the time or if other factors could affect its position.