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INTRODUCTION: There have been concerns around the use of synthetic mesh for stress urinary incontinence (SUI) surgery with a renewed interest in the use of autologous tissues. Recently, an autologous transobturator sling (aTOT) has been described, but the comparative data with synthetic transobturator sling (sTOT) is limited. The objective of this systematic review and meta-analysis was to assess the outcome of aTOT and compare it with sTOT. METHODS: A systematic search of PubMed, Scopus, and Web of Science databases was performed and all articles available up to December 31, 2023 were screened. Studies reporting on the outcomes of aTOT and those comparing aTOT with sTOT were included. This review was performed as per Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RESULTS: Eleven studies evaluating 323 patients that met the criteria were included in the final analysis, of which 6 were single arm (155 patients) and 5 were comparative. In single-arm studies, the pooled success rate, defined as negative cough stress test at 12 months follow-up was 96.8%, 3.8% had postoperative urinary retention, 6.1% had graft site-related complications and 7.6% required additional intervention for persistent SUI. The overall complication rate was 20.6% and there were no Clavien III-V complications. aTOT had similar success and complication rates when compared with sTOT but had a significantly longer operative time (weighted mean difference: 22.35 min, p < 0.00001) and superior sexual function outcomes. CONCLUSIONS: aTOT, at short-term follow-up (12 months), has similar efficacy and complication rates when compared to sTOT. However, given that the data is limited and not of very good quality, and the fact that long-term follow-up is not available, further studies are required to better define the role of aTOT in the management of female patients with SUI.
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AIMS AND METHODS: To find a simpler cure for stress urinary incontinence (SUI) without tapes. Proposed is a paraurethral operation with incisions in both sulci to plicate pubourethral ligaments (PUL) with thick polyester sutures. RESULTS: VIDEO and ultrasound experiments showed the main cause of SUI was weak PULs extending on effort, allowing the posterior pelvic muscles to open out posterior urethral wall, so urine was lost on effort. Midurethral sling (MUS) tapes prevent PUL extension and SUI. The research question: "Would PUL plication by 0.5 or 0.25 mm polyester tapes create sufficient new collagen to cure SUI in the longer term?" Instron-testing of collagen from a rejected polyester aortic graft indicated sufficient potential collagen strength. Five surgeons unrelated to the authors who tested the new operation, reported negative cough tests on 30/31 women before patient discharge; these data were encouraging, but not conclusive. CONCLUSIONS: PUL ligament repair by large polyester sutures, like the MUS, appears to prevent PUL elongation and cure SUI in the very short term, thereby validating the predictions of the Integral Theory as regards the role of ligaments in continence. If successful long term, this operation could avoid many problems associated with MUS operations. 1. Simplicity: less surgical skill is required; the local anesthetic methodology makes the operation widely scalable especially in poor countries with few health facilities. 2. Built-in safety: there is no tape to compress urethra, no applicators to damage bladder, nerves, blood vessels, bowel. 3. Cost: a polyester suture.
Asunto(s)
Cabestrillo Suburetral , Incontinencia Urinaria de Esfuerzo , Femenino , Humanos , Incontinencia Urinaria de Esfuerzo/cirugía , Procedimientos Quirúrgicos Urológicos/métodos , Vejiga Urinaria/cirugía , Ligamentos/cirugíaRESUMEN
INTRODUCTION AND HYPOTHESIS: To assess whether detrusor underactivity (DU) is a risk factor for voiding dysfunction (VD) after transobturator tape (TOT) and if a detrusor pressure at maximum flow (PdetQmax) value predicts postoperative VD in DU patients. Also, we examined uncomplicated patients for postoperative VD. METHODS: This is a prospective long-term study on SUI patients who underwent TOT. Exclusion criteria were preoperative POP stage ≥ 2, previous anti-incontinence surgery and comorbidities. Patients were grouped by detrusor contractility using the projected isovolumetric pressure (PIP) index (PdetQmax + maximum flow rate) with values of 30-75 cmH2O indicating normal contractility. Follow-up was at 1, 3, 6 and 12 months, and then annually. All patients underwent a stress test and responded to the Urogenital Distress Inventory questionnaire and to the King's Health Questionnaire. The subjective cure was evaluated using the Patient Global Impression of Improvement. We determined the diagnostic accuracy of PdetQmax levels using ROC curve analysis, with a cut-off point calculated for optimal sensitivity and specificity. RESULTS: In 2007-2013, 118 patients underwent TOT. We included 50 in the undercontractility group (G1) and 50 in the normocontractility group (G2). Continence rates were 82% in G1 and 84% in G2 (mean follow-up 76 months). VD increased from 18 to 36% (p < 0.05) in G1 and from 14 to 16% (p = 0.198) in G2. De novo VD was 28% in G1 and 2% in G2. In the G1 group PdetQmax ≤ 12 cmH2O predicted postoperative VD with 71.4% specificity and 80.0% sensitivity. CONCLUSIONS: DU adversely affects the voiding phase of micturition after TOT. In DU patients, PdetQmax ≤ 12 cmH2O predicts postoperative VD.