MIDURETHRAL SLINGS: AN UPDATE Prof Ismail Mete Itil, MD President of Turkish Soc. Of Urogynecology Turkısh Soc.of Ob&Gyn Exec. Board Member Ege University, Dept of Ob & Gyn, Izmir, Turkey

STRESS URİNARY INCONTINENCE ( SUI ) the complaint of involuntary loss of urine on effort or physical exertion or on sneezing or coughing.. Joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J (2010) 21:5–26 LUTS, OAB, UI are highly prevalent conditions worldwide. any UI < 20 y. age 2008 250 million women 2018 303 million women

2000-2009 in USA 182110 operation for SUI 80.5 % TVT/TOT 10.5 % Burch op. 9 % the other operations Only 527 Kelly plication  data between 2000 and 2009 from a database containing health care claims data from employer-based plans in the United States.

Midurethral Slings ( MUS ) Integral theory: Petros and Ulmsten* 3 structures are important in urethral closure. Pubourethral ligaments Suburethral vaginal hammock Pubococcygeus muscle * An integral theory of female urinary incontinence. Experimental and clinical consideration. Acta Obstet Gynecol Scand 1990:69 (Suppl 153).

Transobturator tape ( TOT ) De Lorme 2001.. (outside-in) first TOT ( Mentor Porges ) De Leval 2003 (inside-out) Over 500.000 operation worldwide….. No need for cyctoscopy. in obese patients.. in pre-operated patients…. with vaginal operations…. Simple and efficient.. Risk of major complications is lower..

EVOLUTION OF SURGICAL KITS Rapp DE et al Nat. Clınıc Prac Urology 2008 5/4 9

TVT vs Burch/PVS Cochrane (2009) Minimally invasive synthetic suburethral sling operations are highly efficacious both in the short and medium term for treatment of women with SUI with low rates of complications. MUS’s Similar or superior cures/ Burch and PVS perioperative complications voiding dysfunction operation time hospitalisation bladder perforation (6%)

CONCLUSION The TVT operation is durable for 17 years, with a high satisfaction rate and no serious long-term tape induced adverse effects…

excellent objective and subjective outcomes and a low number of re-operations 10 years after retropubic TVT… The small but significant decline in treatment satisfaction 10 years after surgery may be explained by an increase in urgency incontinence symptoms caused by advancing age…

2016

Both the TVT and TOT procedures have demonstrated similar efficacy treating SUI… in the short term (up to one year) the rate of objective and subjective cure of TOR and RPR are similar .. Fewer trials reported medium-term (one to five years) and longer-term (over five years) data, but subjective cure was similar..

MUS procedures performed using the RPR had higher morbidity when compared to TOR, though the overall rate of adverse events remained low. The rate of bladder perforation was lower after TOR .. Major vascular/visceral injury, mean operating time, operative blood loss and length of hospital stay were lower with TOR. Postoperative voiding dysfunction was less frequent following TOR .. Overall rates of groin pain were higher in the TOR group

A retropubic bottom-to-top route was more effective than top-to-bottom route for subjective cure .. Short-and medium-term subjective cure rates between inside-out as opposed to outside-in approach were similar.. they are highly effective in the short and medium term, and accruing evidence demonstrates their effectiveness in the long term..

Effectivity ( cure, improvement) 13 studies 2693 patients Effectivity ( cure, improvement) Good results for SUI component (85-97 %) Changing results for UUI component (30-85 %) Success .. Urgency is predominant No difference in TVT vs TOT…

MUS/ mixed urinary incontinence No difference in the cure rate of SUI symptoms with either TVT or TOT. Higher rates of urgency and urgency incontinence with BC and PVS… These patients need conseling before the operation.. Surgery should be discouraged in patients with predominant urgency and urgency incontinence symptoms ….

MUS and ISD 164 women with SUI + ISD, TVT vs TOT TVT is more effective than TOT 6. month (%79 vs %55) Need for reoperation in 9 patients in the TOT group.. some favor TVT over TOT and PVS over BC, however, there is no consensus.

MUS and Obesity No difference: Rafii et al 2003, Killingsworth et al; 2009, Rechberger et al 2009 Reduced effectiveness when BMI >25 (OR, 2.9) Stav et al 2009 Current evidence does not support the choice of one procedure over the other, however, a MUS may be preferable based on degree of difficulty, operative time, and postoperative morbidity.

MUS in women 65 years and older. The suburethral sling procedure improves continence as well as QoL among elderly women with SUI; however, evidence is limited. Int Urogynecol J (2015) 26:1095–1102 Between TVT and TOT, a TOT is recommended because of less morbidity and voiding dysfunction associated with it..

Recurrent SUI/Rediscovery of open colposuspension? Open colposuspension offers a worthwhile treatment for USI following previous failed midurethral tape. Int Urogynecol J (2012) 23:1117–1122 There were no data to recommend or refuse any of the different management strategies for recurrent or persistent stress incontinence after failed suburethral tape surgery. Evidence is urgently required to address this deficiency, ideally from RCTs.

MINI-SLING Single incision Low morbidity Minimal dissection Out-patient procedure

2014

MINI SLING Women were more likely to remain incontinent after surgery with single-incision slings than with retropubic slings.. Single-incision slings resulted in higher incontinence rates compared with inside-out transobturator slings .. Evidence was insufficient to reveal a difference in incontinence rates with other single-incision slings compared with inside-out or outside in transobturator slings.. TVT-Secur is inferior to standard mid-urethral slings for the treatment of women with stress incontinence and has already been withdrawn from clinical use…

CONCLUSIONS Mıidurethral synthetic slings, revolutionised SUI surgery.. -Reduced morbidity -Shorter hospital stay -Quicker return to work Both the TVT and TOT procedures have similar efficacy treating SUI… MUS are effective in MUI,ISD and obese patients, but there is a need for RCT’s for a conclusion..

CONCLUSIONS Mini-slings have inferior success rates than TVT/TOT.. New devices will continue to be developed and surgeons are advised to examine available data before applying new devices or techniques….