Contemporary trends for urological training and management of stress urinary incontinence in Ireland

Introduction and hypothesis The aim of this study is to evaluate the trends in stress urinary incontinence (SUI) surgery since the 2018 pause on use of the polypropylene (PP) mid-urethral sling (MUS) and to quantify the effect this has had on surgical training. Methods Two anonymous surveys were sent to all current urology trainees and to all consultant surgeons who specialise in stress urinary incontinence surgery. Results Prior to the pause, 86% (6 out of 7) of consultant urologists and 73% (11 out of 15) of consultant gynaecologists would “always”/“often” perform MUS for SUI. After that, 100% (22 out of 22) of consultants reported that they “never” perform MUS. There has been a modest increase in the use of urethral bulking agent (UBA) procedures among urologists, with 43% (3 out of 7) now “often” performing this, compared with 71% (5 out of 7) “never” performing it pre-2018. Trainee exposure to SUI surgery reduced by 75% between 2016 and 2020. Despite a ten-fold increase in UBA procedures logged by trainees, the decline in MUS has resulted in a major reduction in total SUI surgeries. Coinciding with this decrease in surgeries, there was a 56% reduction in trainees’ self-assessed competence at SUI surgery. Thirteen percent of trainees are interested in specialising in Female Urology and those trainees had significantly greater exposure to SUI procedures during their training than those who did not (p = 0.0072). Conclusions This study has identified a downward trend in SUI surgery, which is concerning for the undertreatment of females with SUI. A decline in SUI surgery training has resulted in reduced trainee confidence and interest in this subspecialty.

181 Comparison of Synthetic Mesh Erosion and Chronic Pain Rates After Surgery for Pelvic Organ Prolapse and Stress Urinary Incontinence: A Systematic Review

Background The aim of this study is to systematically compare rates of erosion and chronic pain after mesh insertion for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery. Method A systematic electronic search was performed on studies that evaluated the incidence of erosion and chronic pain after mesh insertion for POP or SUI. The primary outcome measurement was to compare mesh erosion and chronic pain rates for POP and SUI surgery. Results Twenty-six studies on 292,606 patients (n = 9077 for POP surgery and n = 283529 for SUI surgery) met inclusion criteria. The POP group were older (p < 0.0001) and had a lower BMI (p < 0.0001). Mesh erosion rates were significantly greater in the POP group compared to the SUI group (4% versus 1.9%) [OR 2.13; 95% CI 1.91-2.37; p < 0.0001]. The incidence of chronic pain was significantly greater in the POP group compared to the SUI group (6.7% versus 0.6%) [OR 11.02; 95% CI 8.15-14.9; p < 0.0001]. Conclusions The risk of mesh erosion and chronic pain is significantly higher after surgery for POP compared to SUI. Since a higher volume of mesh is typically used for POP surgery this supports evidence for a dose-response relationship between the volume of mesh used and the erosion risk.

Geographical variation in rates of surgical treatment for female stress urinary incontinence in England: a national cohort study

ObjectiveTo examine geographic variation in use of surgery for female stress urinary incontinence (SUI), mainly midurethral mesh tape insertions, in the English National Health Service (NHS).DesignNational cohort study.SettingNHS hospitals.Participants27 997 women aged 20 years or older who had a first SUI surgery in an English NHS Hospital between April 2013 and March 2016 and a diagnosis of SUI at the same time as the procedure.MethodsMultilevel Poisson regression was used to adjust for geographic differences in age, ethnicity, prevalence of long-term illness and socioeconomic deprivation.Primary outcome measureRate of surgery for SUI per 100 000 women/year at two geographic levels: Clinical Commissioning Group (CCG; n=209) and Sustainability and Transformation Partnership (STP; n=44).ResultsThe rate of surgery for SUI was 40 procedures per 100 000 women/year. Risk-adjusted rates ranged from 20 to 106 procedures per 100 000 women/year across CCGs and 24 to 69 procedures per 100 000 women/year across the STP areas. These regional differences were only partially explained by demographic characteristics as adjustment reduced variance of surgery rates by 16% among the CCGs and 35% among the STPs.ConclusionsSubstantial geographic variation exists in the use of surgery for female SUI in the English NHS, suggesting that women in some areas are more likely to be treated compared with women with the same condition in other areas. The variation reflects differences in how national guidelines are being interpreted in the context of the ongoing debate about the safety of SUI surgery.

Choosing the right sling for your patient

Recent data has demonstrated a one in five lifetime risk of a woman requiring stress urinary incontinence (SUI) surgery. Currently, most women opt for a synthetic midurethral sling (MUS), with over 3.6 million placed worldwide. This article attempts to identify whether a gold standard exists with regards to surgical correction of female SUI.When considering which sling type to use for which incontinent woman, the published data demonstrates excellent results for both synthetic mesh (retropubic or transobturator routes) and fascial pubovaginal slings for most patients. Intrinsic sphincter deficiency does appear to be better treated with the use of a retropubic approach, although still with less than stellar results. With little to differentiate, the treatment of most female SUI may be solely based on which sling the surgeon feels most comfortable performing. Currently, most urologists and gynecologists favour synthetic MUS over fascial slings in surgical-naïve patients; however, recent U.S Food and Drug Administration (FDA) warnings concerning the use of mesh in transvaginal surgery have patients questioning the safety of synthetic MUS for the treatment of SUI.

Risk Factors for Urgency Incontinence in Women Undergoing Stress Urinary Incontinence Surgery

Objective.To determine baseline variables associated with urgency urinary incontinence (UUI) in women presenting for stress urinary incontinence (SUI) surgery.Methods. Baseline data from two randomized trials enrolling 1,252 women were analyzed: SISTEr (fascial sling versus Burch colposuspension) and TOMUS (retropubic versus transobturator midurethral sling). Demographic data, POP-Q measures, and validated measures of symptom severity and quality of life were collected. Charlson Comorbidity Index (CCI) and Patient Health Questionnaire-9 were measured in TOMUS. Multivariate models were constructed with UUI and symptom severity as outcomes.Results. Over two-thirds of subjects reported bothersome UUI at baseline. TOMUS patients with more comorbidities had higher UDI irritative scores (CCI score 0 = 39.4, CCI score 1 = 42.1, and CCI score 2+ = 51.0,P=0.0003), and higher depression scores were associated with more severe UUI. Smoking, parity, prior incontinence surgery/treatment, prolapse stage, and incontinence episode frequency were not independently associated with UUI.Conclusions. There were no modifiable risk factors identified for patient-reported UUI in women presenting for SUI surgery. However, the direct relationships between comorbidity level, depression, and worsening of UUI/urgency symptoms may represent targets for preoperative intervention. Further research is necessary to elucidate the pathophysiologic mechanisms that explain the associations between these medical conditions and bladder function.

Is routine cystoscopy justified in female stress urinary incontinence?

The investigation of women with SUI the Serbian urologist traditionally begins with cystoscopy to reduced risk of bladder tumor. There is no doubt regarding its ability to detect bladder cancer presented with characteristic symptoms or pathologic results of urinalyses. We discuss its routine use in patients presenting with symptomatology of SUI. The retrospective study was performed in order to evaluate clinical justifiability and cost/benefit ratio of routine cystoscopy in women with stress urinary incontinence (SUI) whose were surgically treated. We reviewed records of 95 female, mean age 56,5 years (rang 46-78) who underwent SUI surgery at eightyear period. The clinical variables, including urinary symptoms, results of urinalyses, ultrasound records and cystoscopic findings, were obtained from the hospital reports. Insignificantly abnormal cystoscopic findings were reported in 31% patients (vagina - like epithel, trigonitis, uterus wall impression, hyperemia, polypoid proliferation and mild trabeculation). No cases of malignancy were incidentally discovered. In female SUI cystoscopic finding was insignificantly abnormal and was not influenced further therapy and contraindicated the planned SUI surgery. Routine cystoscopy in women with SUI cannot be justified only by customary practice or tradition of older generation urologists.