Tension-free vaginal tape for elderly women with stress urinary incontinence

International Journal of Gynecology and Obstetrics (2006) 92, 48 51 www.elsevier.com/locate/ijgo CLINICAL ARTICLE Tension-free vaginal tape for elderly women with stress urinary incontinence A. Liapis *, P. Bakas, P. Christopoulos, M. Giner, G. Creatsas Second Department of Obstetrics and Gynecology, Aretaieio Hospital, University of Athens, Greece Received 8 February 2005; received in revised form 22 August 2005; accepted 31 August 2005 KEYWORDS Tension-free vaginal tape; Elderly women; Stress incontinence; Incontinence; Efficacy Abstract Objective: To investigate the efficacy of the tension-free vaginal tape (TVT) procedure for the management of stress urinary incontinence (SUI) in elderly women. Method: A total of 55 women aged between 65 and 86 years underwent a TVT procedure for urodynamic SUI. Of these, 15 (27%) had undergone previous surgery for treatment of SUI. Before the TVT procedure, a complete medical history was taken and a gynecologic examination performed. Results: Operating time ranged between 11 and 35 min (excluding the time of concomitant surgery, if any); hospitalization time ranged between 1 and 5 days; and no severe intraoperative or postoperative complications occurred. Cure occurred in 39 (76%) of 51 evaluable patients and its rate was positively associated with bladder neck mobility. Among patients in whom the angle of displacement on the Q-tip test was less than 308, 42% became continent whereas among those in whom it was 308 or higher, 90% became continent ( P b.001). Among those in whom the angle was between 208 and 308, 57% became continent, and among those in whom it was less than 108, 80% remained incontinent. Conclusion: The TVT procedure in elderly women with SUI offers a satisfactory cure rate; however, in patients with significantly decreased bladder neck mobility (an angle b208 on the Q-tip test), the results are not encouraging. D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. 1. Introduction * Corresponding author. N. Paritsi 9A, N. Psichiko, Athens, Greece 15451. Fax: +30 210 6712188. E-mail address: eurotas@panafonet.gr (A. Liapis). The prevalence of urinary incontinence increases from 9% in women aged between 15 and 64 years to 12% in women 65 years and older [1,2]. The increased prevalence of incontinence in late life reflects the compounding effects of functional 0020-7292/$ - see front matter D 2005 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2005.08.025

Tension-free vaginal tape for erderly women with stress urinary incontinence 49 deterioration and coincidental disability [3]. Many conditions worsen with aging. Tissue alterations following menopause; greater likelihood of detrusor instability or low urethral closure pressure; and poor general physical health have been considered to be factors predisposing to postoperative failure of urinary incontinence surgery in elderly women [4]. A better understanding of the pathophysiologic mechanisms underlying stress urinary incontinence (SUI) and the current trend toward less invasive surgical treatments have led to the development of innovative surgical methods, the most recent being the minimally invasive tension-free vaginal tape (TVT) procedure. This study was carried out to assess the efficacy of this procedure for the management of SUI in elderly women. 2. Materials and methods Between October 1998 and April 2003, 55 women with SUI (mean F SD age, 75.4F10.4 years) presented at the Division of Urogynecology of the Second Department of Obstetrics and Gynecology of Aretaieion Hospital, University of Athens, Greece. All patients underwent a procedure using the Tension-free Vaginal Tape (Gynecare, Ethicon, Somerville, NJ, USA). Of the 55 patients, 15 (27%) had previously undergone an ineffective surgical intervention for treatment of SUI: Burch colposuspension (3 patients); Marschall Marchetti Krantz (2 patients) or Stamey (2 patients) procedures; or anterior colporrhaphy (3 patients). Urethral mobility was assessed by means of the Q-tip test, and an angle of displacement greater than 308 while straining was considered positive. A complete medical history was taken and a gynecologic examination was performed. A complete urodynamic study was performed 1 year after the procedure and yearly thereafter for up to 3 years. Urinalysis and urine culture results before urodynamic studies were in each case negative. The patients were assessed by filling and voiding cystometry and uroflowmetry. The maximum urethral closure pressure test was performed using a soft dual-channel microtransducer catheter. Cure was defined as no loss of urine during a cough stress test with the bladder filled at maximum cystometric capacity or at a volume of 450 ml. All procedures were performed by the same surgeon. Epidural anesthesia was used in 44 (87%) of the 51 patients and local anesthesia was used in 7 (13%) patients, and 2 g of intravenous cefoxitin was administered intraoperatively as a single dose (Mefoxil; Vianex Co., Athens, Greece). Eight patients had concomitant anterior colporraphy for cystocele repair; 4 had vaginal hysterectomy; and 8 had posterior colporraphy. In all cases cystoscopy with a 708 lens was performed intraoperatively to check for bladder perforation. The catheter was removed the day after the procedure in 49 cases, and in 2 cases it was removed 5 days after the procedure because of bladder perforation. All patients were followed up for 36 months, except for 4 who were lost to follow-up. 3. Results Mean operating time for the TVT procedure was 18 min (range, 11 35 min), excluding the time for concomitant surgery, and mean hospitalization duration was 1.6 days (range, 1 5 days). Preoperatively, a positive result on the Q-tip test was found in 39 (76%) of the 51 evaluable patients. The overall cure rate was 76.4%. Among patients in whom the angle of displacement on the Q-tip test was less than 308, 42% became continent whereas among those in whom it was 308 or higher, 90% became continent ( P b.001). Among the 5 patients in whom the angle was less than 108, 4 (80%) remained incontinent, and among the 7 patients in whom the angle was between 208 and 308, 4 (57%) became continent. Of the 51 evaluable patients, 12% presented de novo urgency postoperatively. Maximal flow rate and bladder volume at first desire to void, mean functional urethral length, maximal urethral closure pressure, resting urethral pressure profile, and cystometric capacity did not show any significant change 1 year after surgery (Table 1). No skin or vaginal infections were observed. In 1 patient, vaginal erosion was reported 45 days postoperatively. This patient was treated by covering of the Table 1 Preoperative and postoperative urodynamic findings in patients 1 year after undergoing the tension-free vaginal tape procedure* Preoperative Postoperative P value Q max, ml/s 19.6F4.1 14.8F3.7 N.05 PVR, ml 38.9F21.7 39.3F21.9 N.05 FDV, ml 98.1F19.3 105.4F19.7 N.05 CC, ml 323.2F80.3 335.5F85.2 N.05 MUCP, cm H 2 O 52.9F12.5 55.2F13.3 N.05 FUL, mm 20.1F4.7 21.0F4.2 N.05 D max,cmh 2 O 9.4F3.9 9.8F3.6 N.05 Abbreviations: Q-max, maximum flow; PVR, post-void urine; FDV, first desire to void; CC, cystometric capacity; MUCP, maximum urethral closure pressure; FUL, functional urethral length; D max, maximum detrusor pressure. Values are given as mean F SD.

50 tape with a vaginal strip after removal of the affected tissue. Perforation of the bladder occurred in 2 patients, in whom an indwelling catheter was inserted and maintained for 5 days. No subsequent urinary complications were noted. Antibiotics were given to 4 patients in whom cystitis developed postsurgically, and urethral dilation using a Hegar dilator No. 7 lubricated with 2% xylocaine gel was performed in 4 patients who had a residual urine volume between 140 and 190 ml. 4. Discussion Although stress urinary incontinence, a financial burden and a condition that considerably decreases the quality of life and self-esteem of many women, is the most common form of incontinence, it is underdiagnosed [1]. During the last century, the pathophysiology of stress urinary incontinence was investigated and a broad range of possible interventions were utilized for cure. When conservative methods such as absorbent pads, vaginal weights and cones, and biofeedback prove inadequate, surgical approaches for the correction of SUI are proposed [5]. The most recent evolution in the management of SUI is the minimally invasive TVT procedure, which follows the current trend toward less invasive surgical treatments. The TVT creates a backboard that produces compression of the urethra when it rotates posteriorly during cough or stress. The procedure accomplishes subjective and objective cure without elevating the bladder neck or altering urethral mobility [2]. Recent multicenter studies have shown that the TVT procedure has the same short-term and medium-term results as the Burch colposuspention [6,7]. Only a few studies have assessed the outcome of the TVT procedure in elderly women. The prevalence of detrusor overactivity is high among women older than 80 years, and the detrusor activity pattern may not always be disclosed during cystometry in women [8]. Elderly women often have a thin bladder with low contractility, and this is an additional reason for the development of urinary retention [8]. Aging introduces structural changes in collagen quality and cholinergic innervation of the bladder wall [9] that create gaps in the base of bladder. Low maximum urethral closure pressure is an important factor for the lower success rate of anti-incontinence procedures in elderly women. The mean hospitalization time in the present study was 1.6 days (range, 1 5 days). Most studies report a number of days of hospital stay, which rises according to postoperative complications [4,10]. Bladder perforation occurred in 2 of 51 cases (3.9%), a rate similar to that reported by other investigators [10].The main reason for low perforation rates in this study is without doubt the surgical experience of the gynecologist who performed all procedures. In this study, 39 (76%) of the 51 patients were cured, a rate similar to the 80% to 85% rates reported in other studies [8]. De novo postoperative urgency occurred in 12% of the patients who no longer were incontinent. Higher rates of de novo urgency have been reported in younger women [11], while a 25% postoperative urgency without incontinence has also been reported [12]. De novo urgency may be related to changes in the metabolism of paraurethral collagen and a potential sclerosis around the prolene tape. It has been reported that collagen metabolism alteration induced by intravaginal slingplasty is dependent on patient age and hormonal status [13]. Fifteen percent of the women reported voiding difficulties, with a feeling of incomplete emptying of the bladder. Postoperative voiding difficulties may occur as a result of poor detrusor function or urethral obstruction secondary to excessive sling tension [1]. Rezapour and Ulmsten noticed postoperative voiding difficulties in 18% of cases [12], but 4.3% of these women experienced no more than 4 days of urinary retention problems [10]. There were no postoperative infections, and other authors have reported the same in their studies [10,12]. The TVT procedure appears to offer improved safety and minimum hospital stay, while maintaining the efficacy of traditional open incontinence surgery. It is individualized, and therefore more women of different ages and levels of medical fitness can be offered the choice of a safe and effective treatment for SUI. The presence of significantly reduced proximal urethral mobility preoperatively (an angle of displacement b 208 on the Q-tip test) is a poor prognostic indicator of the outcome of the operation. References A. Liapis et al. [1] Thomas TM, Flyman KR, Blannin J, Meade TW. The prevalence of urinary incontinence. BMJ 1980;281:1243 5. [2] Brocklehurst JC. Urinary incontinence in the community: analysis of a MORI poll. BMJ 1993;306:832 4. [3] Ding YY, Lieu PK, Choo PW, Tjia TT. Urinary incontinence after ischaemic stroke: predictive factors for its prevalence. Neurourol Urodyn 1996;15:262 4.

Tension-free vaginal tape for erderly women with stress urinary incontinence 51 [4] Lo Tsia-shu, Huang Huei-jean, Chang Chia-lin, Wong Shug-gwo, Horng Shang-gwo, Liang Ching-chung. Use of intravenous anesthesia for tension-free vaginal tape therapy in elderly women with genuine stress incontinence. Urology 2002;59:349 53. [5] Stoffel JT, Bresette JF, Smith JJ. Retropubic surgery for stress urinary incontinence. Urol Clin North Am 2002; 29:585 96. [6] Liapis A, Bakas P, Creatsas G. Burch colposuspension and tension-free vaginal tape in the management of stress urinary incontinence in women. Eur Urol 2002;41:469 73. [7] Manca A, Sculpher MJ, Ward K, Hilton P. A cost utility analysis of tension free vaginal tape versus colposuspension for primary urodynamic stress incontinence. BJOG 2003; 110:255 62. [8] Kinn AC. Tension-free vaginal tape evaluated using patient self-reports and urodynamic testing. Scand J Urol Nephrol 2001:484 90. [9] Elbadawi A, Resnick NM, Dorsam J, Yalla SV, Haferkamp A. Structural basis of neurogenic bladder dysfunction: methods of prospective ultrastuctural study and overview of findings. J Urol 2003;169:540 6. [10] Sevestre S, Ciofu C, Deval B, Traxer O, Amarenco G, Haab F. Results of the tension-free vaginal tape technique in the elderly. Eur Urol 2003;44:128 31. [11] Jeffry L, Deval B, Birsan A, Soriano D, Darai E. Objective and subjective cure rates after tension-free vaginal tape for treatment of urinary incontinence. Urology 2001; 58:702 6. [12] Rezapour M, Ulmsten U. Tension-free vaginal tape (TVT) in women with mixed urinary incontinence: a long-term follow-up. Int Urogynecol J(suppl 2):S15 8. [13] Falconer C, Ekman-Ordeberg G, Malmstrfm A, Ulmsten C. Clinical outcome and changes in connective tissue metabolism after intravaginal slingplasty in stress incontinence women. Int Urogynecol J 1996;7:133 7.

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