Female Urology: SUI procedures show decrease following sling warnings

A comparison of autologous fascial pubovaginal and synthetic midurethral slings and a study examining onabotulinumA (Botox) injections in the elderly population were among other female urology take-homes from AUA 2018. The take-homes were presented by Tracey S. Wilson, MD, of the University of Alabama, Birmingham.

• Prior to regulatory warnings regarding synthetic slings from Health Canada and the FDA (from 2000 to 2009), stress incontinence procedures increased from 95 to 147/100,000 persons, primarily due to increased utilization of synthetic slings. After the regulatory warnings (from 2009 to 2016), the overall number of stress incontinence procedures declined from 147 to 64/100,000 persons. This decline was due not only to decreasing utilization of synthetic slings but to a decrease in all procedures for stress incontinence, suggesting many patients living with stress incontinence symptoms are foregoing treatment.
• A review of data over a 40-year span did not show a high rate of serious complications associated with autologous fascial pubovaginal slings versus synthetic midurethral slings. In fact, fascial slings had a higher rate of wound complications only. Midurethral slings had a higher rate of erosion, refractory pelvic pain, bowel perforation, and de novo overactive bladder (OAB) symptoms. Bladder perforation and urethral obstruction surprisingly were reported equally in both procedures.
• A contemporary series of patients undergoing autologous rectus fascia pubovaginal sling procedures showed 115 complications. Wound complications, including seroma, hematoma, and dehiscence, were reported in 13.2%. Urinary retention was reported at 11.7% of patients. Those with complications were most likely to have had prior stress incontinence surgery and chronic preoperative pain syndromes.
• Among women who underwent revision of a synthetic mid-urethral sling and who presented with very complex presentations of exposure or erosion, pain or dyspareunia, incontinence, and bladder outlet obstruction, 70% did not require a second procedure at 14-month follow-up. There was a significant decrease in the number of patients reporting pain/dyspareunia and incontinence, and there was significant improvement in post-void residual (PVR) and number of pads used. 
• Urinary incontinence was reported in 56% of patients at 8.4 months follow-up following sling revision for the indications of pelvic or perineal pain. The incontinence was mild and did not require repeat surgery in one-third of patients. 41% of those with recurrent urinary incontinence did require repeat surgery.
• Among patients undergoing midurethral sling revision, risk factors for those requiring additional stress incontinence surgery included increasing time to midurethral sling excision and total midurethral sling excision versus partial excision, and stress incontinence on preoperative urodynamics. Factors that did not predict repeat stress incontinence surgery included age, vaginal parity, prior hysterectomy, smoking status, type of midurethral sling excised, history and type of prior midurethral sling excision, and location of the midurethral sling along the urethra at the time of excision.
• Following laparoscopic sacrocolpopexy, patients with Stage 3-4 pelvic organ prolapse had statistically significant improvements in urgency and voiding dysfunction symptoms, objective improvement in maximum flow rate, and a decrease in maximum detrusor pressure. Bladder outlet obstruction resolved in 11 of 15 patients.
• Bladder outlet obstruction index and PdetQmax are poorly predictive of voiding efficiency (defined as voided volume/capacity) and/or post void residual volume following prolapse surgery. Also, women with bladder contractility index <60, capacity >600 cc, or PVR >200 cc are at risk of worsening voiding efficiency and/or PVR following prolapse repair.
• Among women undergoing prolapse mesh removal for pain, no significant difference was seen in pain resolution in those undergoing complete versus partial mesh removal, but recurrent prolapse was reported more frequently with complete versus partial removal (35% vs. 15%). Overall, 27% of patients required repeat reconstructive procedures after mesh removal.
• The number of obese or overweight years was associated with an increased risk of developing urinary incontinence and severity of incontinence postmenopausally. In men and women, central obesity was associated with the presence of any urinary incontinence and overactive bladder.
• Despite 86% of patients having significant improvement in OAB after their first onabotulinumA (Botox) injection, only 50% return for a second injection. Patients with multiple injections had more symptomatic improvement as well as a preoperative diagnosis of neurologic disorders.
• OnabotulinumA, 100 U, improved urinary symptoms and quality of life, and there was no increase in risk of clean intermittent catheterization (CIC) with reinjection. Only 1.7% of patients required CIC after both a first and second injection.
• OnabotulinumA injections are safe and effective in the elderly population. The urinary retention rate was 11% in octogenarians and nonagenarians versus 4% in those age 50-70 years, and there were no statistically significantly differences in UTIs or satisfaction between the two groups.
• Patients with detrusor hyperactivity and impaired contractility have significant improvement after sacral neuromodulation, with >50% improvement in subjective symptoms as well as a decline in PVR volumes to <100 cc. Overall success rate was 80%.
• OnabotulinumA is efficacious in patients with incontinence and an existing suprapubic (SP) tube catheter or concomitant placement of an SP catheter at time of injection and may be considered in this poplulation. There was subjective improvement in 88%, and patients returned for subsequent injections (mean number of injections, 3.26). Complications were seen in 10%, the most common being UTI and hematuria.