1. Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures J.-M. Yang, S.-H. Yang, W.-C. Huang and C.-R. Tzeng Volume 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

2. 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.

3. Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures Yang et al, UOG, 2012 Objective To explore, using 4D ultrasound, the importance of location and tension of transobturator suburethral tape (TOT) with respect to clinical outcome measures.

4. 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 approach a) 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

5. sTSD: sagittal tape–symphysis pubis distance (dashed double-headed arrow) sTSA: sagittal tape–symphysis pubis angle Tape percentile: percentage of proximal urethral length (PUL) by total urethral length (TUL) (double-headed arrows) B, bladder; SP, symphysis pubis; T, tape; U, urethra Tape location measurements Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures Yang et al, UOG, 2012

6. 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 Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures Yang et al, UOG, 2012 B, bladder; SP, symphysis pubis; T, tape; U, urethra

7. aUCEAc, circle: urethral central echolucent area at the tape center in the axial plane SP, symphysis pubis; U, urethra; T, tape Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures Yang et al, UOG, 2012 Tape tension measurements

8. Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures Yang et al, UOG, 2012 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)

9. 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) MeasurementIntraobserverInterobserver Resting sTSD0.840 (0.639–0.933)0.794 (0.551–0.913) sTSA0.799 (0.559–0.915)0.831 (0.622–0.930) Straining sTSD0.795 (0.552–0.913)0.851 (0.661–0.938) sTSA0.747 (0.465–0.892)0.857 (0.674–0.941) Coughing sTSD0.769 (0.504–0.902)0.807 (0.576–0.919) sTSA0.852 (0.664–0.939)0.805 (0.571–0.918)

10. 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

11. Conclusions Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures Yang et al, UOG, 2012 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.

12. Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures Yang et al, UOG, 2012 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

13. Correlation of tape location and tension with surgical outcome after transobturator suburethral tape procedures Yang et al, UOG, 2012 Related articles Chantarasorn V, Shek K, Dietz H. Sonographic appearance of transobturator slings: implications for function and dysfunction. Int Urogynecol J, 22:493-49 (2011).Sonographic appearance of transobturator slings: implications for function and dysfunction 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).Tape functionality: position, change in shape, and outcome after TVT procedure-mid-term results Dietz H, Barry C, Lim Y, Rane A. TVT vs Monarc: a comparative study. Int Urogynecol J, 17: 566-569 (2006).TVT vs Monarc: a comparative study 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).The Iris Effect: how 2D and 3D volume ultrasound can help us understand anti-incontinence procedures 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).Reliability of a new method for assessing urethral compression following midurethral tape procedures using four-dimensional ultrasound.