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Frailty has emerged as a significant predictor of morbidity in urological surgery, but its impact on outcomes of sling surgery for stress incontinence remains unclear. The purpose of this study is to describe the prevalence of frailty among women undergoing sling surgery and determine the association of frailty with 30-day postoperative outcomes.We analyzed data from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP®) in 2013-2016 to identify patients undergoing sling placement using Current Procedural Terminology, 10th edition, code 57288. Patients were categorized into 2 groups based on whether they underwent isolated sling placement or had a sling with concomitant prolapse surgery. Frailty was assessed using the 5-factor Modified Frailty Index (mFI-5) developed for use with the NSQIP data set. Patients were considered frail if 2 or more factors from the mFI-5 were present. Outcomes and complications within 30 days were captured from the NSQIP data and logistic regression models used to adjust for age, race/ethnicity, body mass index and frailty.We identified 25,887 women who underwent sling placement, 15,087 of whom underwent isolated sling placement (Group 1) and 10,800 of whom underwent sling with concomitant prolapse repair surgery (Group 2). Frailty was present in 9.3% of patients in Group 1 and 10.2% of patients in Group 2 (p=0.0122). Among those who underwent isolated sling placement, frailty was associated with increased length of hospital stay (OR 1.2, 95% CI 1.1-1.4, p=0.0008) and 30-day hospital readmission (OR 1.7, 95% CI 1.1-2.5, p=0.0093). Older patients undergoing isolated sling placement were more likely to have longer operation time (OR 1.2, 95% CI 1.1-1.3, p0.0001) and hospital length of stay (OR 1.3, 95% CI 1.2-1.4, p0.0001). Frailty was also associated with increased 30-day hospital readmission in patients who underwent sling with concomitant prolapse repair (OR 1.8, 95% CI 1.3-2.6, p=0.0003), while age was not (OR 0.9, 95% CI 0.7-1.1, p=0.29).We found that frailty was present in relatively few patients undergoing sling surgery. Adverse postoperative outcomes and complications were low overall. Increased age and frailty were both associated with longer length of stay. Frailty, but not age, was significantly associated with increased likelihood of hospital readmission within 30 days following surgery. Our findings provide insight into the preoperative characteristics of women undergoing sling surgery in a large national sample, suggesting the need for preoperative identification of the frail patient.

Stress urinary incontinence following radical prostatectomy is common and potentially debilitating. Surgical therapy with a urethral sling or an artificial urinary sphincter is an effective option with high patient satisfaction in men in whom conservative measures fail to treat post-prostatectomy incontinence. We sought to characterize the contemporary utilization of surgical therapy of post-prostatectomy incontinence using an all payer database.We used the Healthcare Cost and Utilization Project databases for Florida from 2006 to 2015 and identified men who underwent radical prostatectomy between 2006 and 2012 using ICD procedure codes. Patients were tracked longitudinally for placement of an ambulatory or inpatient urethral sling, or an artificial urinary sphincter between 2006 and 2015. Patient and clinical data were extracted and analyzed with descriptive statistics. A multivariable logistic regression model was constructed to determine risk adjusted predictors of subsequent incontinence surgery.During the study period 29,287 men underwent radical prostatectomy, of whom 1,068 (3.6%) were treated with subsequent incontinence surgery a median of 23.5 months after prostatectomy. On multivariate analysis risk factors for incontinence surgery included age groups 61 to 70 years (OR 1.25, p=0.008) and 71 to 80 years (OR 1.34, p=0.022), Medicare insurance (OR 1.33, p0.005) and an increased Charlson Comorbidity Index (OR 1.13 per unit increase, p0.005).Of patients who underwent radical prostatectomy 3.6% subsequently underwent stress urinary incontinence surgery. Post-prostatectomy incontinence surgery is likely under performed and delayed in performance based on the previously reported prevalence of severe post-prostatectomy incontinence and the natural history of symptoms. Efforts to increase prompt repair of refractory or severe incontinence can greatly improve patient quality of life after radical prostatectomy.

The objective of this study was to examine national trends in the surgical management of urinary incontinence in women in the United States from 2004 to 2013.We analyzed the CDM (Optum® de-identified Clinformatics® Data Mart) for women 18 to 64 years old and the CMS (Centers for Medicare and Medicaid Services) Medicare 5% Sample for women 65 years old or older. We created annual cross-sectional cohorts and assessed trends in the annual prevalence of urinary incontinence related surgical procedures overall and by age, race/ethnicity and geographic region.We observed a decline in the percent of women with urinary incontinence who underwent surgical treatment according to the CMS (from 4.7% in 2004 to 2.7% in 2013) and the CDM (from 12.5% in 2004 to 9.1% in 2013). This trend persisted independently of age, race/ethnicity and geographic region. Slings were the most common procedure but started to decline in 2011, ultimately decreasing by about 50% during the study period. Compared to other groups the prevalence of urinary incontinence related surgical procedures, including slings, was highest among women 35 to 54 years old and White women, and lowest among women residing in the Northeast. These sociodemographic patterns persisted with time. During the study period injection procedures remained stable, sacral neuromodulation increased slightly but remained uncommon and suspension decreased to nearly 0% of all anti-incontinence procedures.Surgical management of female urinary incontinence experienced several shifts from 2004 to 2013, including a decline in sling procedures. Age, racial/ethnic and regional differences in treatment persisted with time. Improved understanding of the drivers of these trends may help direct future development of treatments of pelvic floor disorders.

The purpose of our study was to describe the symptom profile of patients who presented to a tertiary care hospital for sling revision, define the efficacy of sling removal/revision in alleviating symptoms and identify what factors, if any, contribute to favorable surgical outcomes.We retrospectively reviewed the records of patients who underwent revision of a synthetic mid urethral sling at our institution between 2004 and 2016. Patients with a history of vaginal mesh for pelvic organ prolapse were excluded from analysis. The outcomes assessed were the AUASI (American Urological Association Symptom Index) score, the M-ISI (Michigan Incontinence Symptom Index) score, pad use, post-void residual urine volume, examination findings and subjective improvement.A total of 430 patients met study inclusion criteria, of whom 182, 172 and 40 received a transobturator tape, a retropubic mid urethral sling and a mini-sling, respectively. Patients presented with 4 primary complaints, including mesh exposure or erosion, pain or dyspareunia, incontinence and/or bladder outlet obstruction. Of the patients 77% presented with at least 2 categories of symptoms. Average followup was 15 months. Postoperatively the AUASI score decreased from 19.0 to 14.7 (p0.001) and the bother score decreased from 5.0 to 3.4 (p0.001). The M-ISI also improved from total and bother scores of 15.7 and 4.4 to a postoperative average of 13.2 and 3.1 (p = 0.002 and0.001, respectively). During this time approximately 40% of patients who presented with pain had persistent postoperative discomfort, in 20% with obstruction that condition failed to resolve and recurrent mesh complaints developed in 5% with mesh exposure or erosion. On multivariate analysis preoperative narcotic use was a significant risk factor for persistent postoperative pain (OR 6.9).Despite complex patient presentations subjective and objective urological symptom measures significantly improve following mid urethral sling revision.

The efficacy and safety of retropubic and transobturator tension-free vaginal tape mid urethral slings remain controversial in patients with stress urinary incontinence and risk factors for recurrence. We compared the techniques after initial mid urethral sling insertion in select groups, including patients with obesity, intrinsic sphincter deficiency, pelvic organ prolapse and recurrent stress urinary incontinence.We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement to report the methods and results of the current review. Randomized controlled trials and observational studies were included. We assessed the objective and subjective cure rates, and the complication rate using the OR with the 95% CI. The protocol of the current meta-analysis was registered on PROSPERO (No. CRD42018102233).We retrieved 28 studies in a total of 2,607 patients to compare the efficacy and safety of retropubic vs transobturator tension-free vaginal tape in select groups (mean followup 26.9 months). Meta-analysis of the objective cure rate showed the significant superiority of retropubic compared to transobturator tension-free vaginal tape in patients overall (OR 3.37, 95% CI 2.55-4.43, p0.00001, IThe meta-analysis showed the superiority of retropubic tension-free vaginal tape over transobturator tension-free vaginal tape in terms of the objective and subjective cure rates in patients with obesity, intrinsic sphincter deficiency, pelvic organ prolapse and recurrent stress urinary incontinence after mid urethral sling insertion. Retropubic tension-free vaginal tape also has morbidity comparable to that of transobturator tension-free vaginal tape.

To our knowledge there are no guidelines for the evaluation and management of incontinence in women with an orthotopic neobladder. We propose a treatment algorithm based on our experience with treating this patient population.We identified women in whom orthotopic neobladder diversion and surgery for incontinence were performed from January 1, 1995 to January 1, 2014. Charts were reviewed for management, outcomes and complications within 30 days of surgery.At this institution 12 women with orthotopic neobladder diversion were treated with surgery for incontinence between 1995 and 2014. Six women (50%) had an undiagnosed neovesicovaginal fistula, of whom 3 (50%) underwent successful fistula repair. A total of 12 bulking agent injections were performed in 6 women (50%). The outcomes were continued dryness after 1 injection (8%), transient improvement after 9 (75%), immediate failure after 1 (8%) and secondary fistula development after 1 (8%). Four transobturator slings and 4 pubovaginal slings were placed in a total of 6 patients (50%), of whom 1 (17%) was dry and 1 (17%) was improved. At a median followup of 22.9 months (IQR 11.1-46.4) 6 women (50%) were dry or improved and 6 (50%) had no improvement in leakage. Of the 6 (50%) women who were dry or improved 2 (17%) achieved planned intermittent catheterization after surgery and 2 (17%) underwent ileal conduit conversion.Bulking agents have low long-term efficacy and carry the risk of fistula formation. The efficacy of tension-free sling placement is low and continence requires an obstructing sling. Counseling should include acceptance of multiple procedures, which may be necessary to achieve continence, and consideration of conduit diversion.

We determined the rate of recurrent female stress urinary incontinence after retropubic urethrolysis without a concomitant anti-incontinence procedure.We reviewed the charts of all women who underwent urethrolysis at our institution for urethral obstruction due to an anti-incontinence procedure. The study was limited to patients who underwent retropubic urethrolysis without a synchronous anti-incontinence operation or interposition flap inlay for obstruction associated with a suburethral sling. Variables reviewed included the history of urethrolysis, success of retropubic urethrolysis and incidence of urinary incontinence after the operation.A total of 12 patients met our study criteria, of whom 1 had stress urinary incontinence before retropubic urethrolysis. Of the 12 patients 10 achieved a successful result after urethrolysis and 2 achieved improvement but not success secondary to urinary urge incontinence. Protective padding was needed postoperatively for urinary incontinence in 5 of the 12 cases, including 3 (25%) and 2 (17%) due to stress and urgency incontinence, respectively. New onset stress urinary incontinence developed postoperatively in 2 of the 11 patients (18%) who did not have stress urinary incontinence before retropubic urethrolysis. A history of failed urethrolysis did not significantly increase the urinary incontinence rate postoperatively.Although retropubic urethrolysis has a high potential success rate for resolving urethral obstruction, it may cause a higher incidence of recurrent stress urinary incontinence than transvaginal approaches. There is no clear need for a synchronous anti-incontinence procedure at the time of retropubic urethrolysis.