correlation of tape location and tension with surgical outcome after transobturator suburethral tape...

Correlation of tape location and tension with surgical outcome after transobturator suburethral

tape proceduresJ.-M. Yang, S.-H. Yang, W.-C. Huang and C.-R. TzengVolume 39, Issue 4, Date: April 2012, pages 458–465

Journal Club slides prepared by Tommaso Bignardi(UOG Editor for Trainees)

UOG Journal Club: April 2012

Background

Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures

Yang et al, UOG, 2012

Tape location and tension are among the factors that might affect surgical outcome of transobturator suburethral tape procedures (TOTs).

The location and course of the suburethral tape can be studied with translabial and/or transperineal sonography.



Objective

To explore, using 4D ultrasound, the importance of location and tension of transobturator suburethral tape (TOT) with respect to clinical outcome measures.

Exclusion criteria:Diabetes, neurological disease or stroke, previous or concomitant pelvic reconstructive surgery, concurrent symptoms of urgency or urgency incontinence, ≥ Stage II pelvic floor prolapse, detrusor overactivity

4D ultrasound assessments using an introital approacha) at rest, b) during maximum strain and c) with coughing

Prospective observational study of 56 women who had TOT (Monarc®) for urodynamic stress incontinence

Methodology

sTSD: sagittal tape–symphysis pubis distance (dashed double-headed arrow)sTSA: sagittal tape–symphysis pubis angleTape percentile: percentage ofproximal urethral length (PUL) by total urethral length (TUL)(double-headed arrows)

B, bladder; SP, symphysis pubis;T, tape; U, urethra

Tape location measurements



sTUDu, sTUDc and sTUDl: shortest distance between upper, center and lower ends, respectively, of the tape and the midline of the urethral echolucent area in the sagittal plane

Urethral encroachment: indentation in the urethral outer wall by the tape with an elevation of the inner wall and narrowing of the echolucent urethral core

Tape tension measurements



B, bladder; SP, symphysis pubis;T, tape; U, urethra

aUCEAc, circle: urethral central echolucent area at the tape center in the axial plane

SP, symphysis pubis; U, urethra;T, tape



Tape tension measurements



Surgical outcomes

Postoperative assessments: 3 months,12 months and 24 months

Incontinence severity: Sandvik Incontinence Severity Index and Ingelman- Sundberg Scale

Quality of life: short forms of Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7)

Results

The intra- and interobserver reliability of ultrasound measurements of sagittal tape–symphysis pubis distance (sTSD) and sagittal tape–symphysis pubis angle (sTSA) were good to very good.

ICC (95% CI)Measurement Intraobserver InterobserverResting sTSD 0.840 (0.639–0.933) 0.794 (0.551–0.913) sTSA 0.799 (0.559–0.915) 0.831 (0.622–0.930) Straining sTSD 0.795 (0.552–0.913) 0.851 (0.661–0.938) sTSA 0.747 (0.465–0.892) 0.857 (0.674–0.941) Coughing sTSD 0.769 (0.504–0.902) 0.807 (0.576–0.919) sTSA 0.852 (0.664–0.939) 0.805 (0.571–0.918)

• TOT placement is associated with increased sTSA and urethral encroachment and decreased sTUDu, sTUDc, sTUDl and aUCEAc during increased intra-abdominal pressure.

• Tapes in women with recurrent SUI were placed more proximally.

• Women with SUI postoperatively demonstrated no urethral encroachment at rest or with increased intra-abdominal pressure.

• Women with postoperative OAB symptoms had decreased resting sTSD and larger resting sTSA.

• Women reporting de novo or worsening voiding difficulty had increased resting sTSA and urethral encroachment.

SUI, stress urinary incontinence; OAB, overactive bladder

Results

Conclusions



•Both tape location and tape tension are associated with surgical outcome of TOT procedures.

•Assessment of tape location and tension can be achieved using 4D ultrasound.



• How do suburethral slings work?• Do you think we have to compress the urethra to achieve stress continence? • Why would you want to know whether a suburethral sling is too tight, just right or

too loose?

• What kind of symptoms would you expect if a tape was too tight/too loose? What parameters does this paper suggest we measure to define tape 'tightness'?

• Do you know of any other, simpler sonographic measures? (see ref. 1 below) • Would the findings in this paper regarding de novo overactive bladder symptoms

and worsening voiding difficulty be altered by statistical correction for multiple comparisons?

• Apart from ultrasound, what other investigations would you suggest? What would you do if symptoms and investigations suggest a tape that's too tight? And what would you do if it's clearly too loose?

• What can we do to get sling tension right every time? • Do you think ultrasound can help?

Discussion points



Related articlesChantarasorn V, Shek K, Dietz H. Sonographic appearance of transobturator slings: implications for function and dysfunction. Int Urogynecol J, 22:493-49 (2011).

Kociszewski J, Rautenberg O, Kolben S, Eberhard J, Hilgers R, Viereck V. Tape functionality: position, change in shape, and outcome after TVT procedure-mid-term results. Int Urogynecol J, 21: 795-800 (2010).

Dietz H, Barry C, Lim Y, Rane A. TVT vs Monarc: a comparative study. Int Urogynecol J, 17: 566-569 (2006).

Dietz H, Wilson P. The Iris Effect: how 2D and 3D volume ultrasound can help us understand anti-incontinence procedures. Ultrasound Obstet Gynecol, 23: 267-271 (2004).

Yang JM, Yang SH, Huang WC, Tzeng CR. Reliability of a new method for assessing urethral compression following midurethral tape procedures using four-dimensional ultrasound. Ultrasound Obstet Gynecol, 38: 210-216 (2011).

correlation of tape location and tension with surgical outcome after transobturator suburethral tape...

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